Chapter 14

Question 1

A client became severely depressed when the last of the family’s six children moved out of the home 4 months ago. The client repeatedly says, “No one cares about me. I’m not worth anything.” Which response by the nurse would be the most helpful?

a. “Things will look brighter soon. Everyone feels down once in a while.”
b. “Our staff members care about you and want to try to help you get better.”
c. “It is difficult for others to care about you when you repeatedly say the same negative things.”
d. “I’d to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you.”

Answer 1

d. “I’d to sit with you for 10 minutes now and 10 minutes after lunch because I value spending time with you.”

Question 2

A client became depressed after the last of the family’s six children moved out of the home 4 months ago. Select the best initialmoutcome for the nursing diagnosis Situational low self-esteem related to feelings of abandonment.

a. The client will verbalize realistic positive characteristics about self by (date).
b. The client will agree to take an antidepressant medication regularly by (date).
c. The client will initiate social interaction with another person daily by (date).
d. The client will identify two personal behaviors that alienate others by (date).

Answer 2

a. The client will verbalize realistic positive characteristics about self by (date).

Question 3

A client diagnosed with major depressive disorder says, “No one cares about me anymore. I’m not worth anything.” Today the client is wearing a new shirt and has neat, clean hair. Which remark by the nurse supports building a positive self-esteem for thismclient?

a. “You look nice this morning.”
b. “You’re wearing a new shirt.”
c. “I like the shirt you are wearing.”
d. “You must be feeling better today.”

Answer 3

b. “You’re wearing a new shirt.”

Question 4

An adult diagnosed with major depressive disorder was treated with medication and cognitive-behavioral therapy. The client now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?

a. Social skills training
b. Relaxation training classes
c. Desensitization techniques
d. Use of complementary therapy

Answer 4

a. Social skills training

Question 5

What is the priority intervention for a client diagnosed with major depressive disorder and feelings of worthlessness?

a. distracting the client from self-absorption.
b. careful unobtrusive observation around the clock.
c. allowing the client to spend long periods alone in meditation.
d. opportunities to assume a leadership role in the therapeutic milieu.

Answer 5

b. careful unobtrusive observation around the clock.

Question 6

When counseling clients diagnosed with major depressive disorder, what therapy would an advanced practice nurse address the client’s negative thought patterns?

a. psychoanalytic
b. desensitization
c. cognitive-behavioral
d. alternative and complementary

Answer 6

c. cognitive-behavioral

Question 7

A client says to the nurse, “My life doesn’t have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” The nurse documents this report using what medical term?

a. dysthymia.
b. anhedonia.
c. euphoria.
d. anergia.

Answer 7

b. anhedonia.

Question 8

A client diagnosed with major depressive disorder began taking a tricyclic antidepressant 1 week ago. Today the client says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse will implement which intervention?

a. limit the client’s activities to those that can be performed in a sitting position.
b. withhold the drug, force oral fluids, and notify the health care provider.
c. teach the client strategies to manage postural hypotension.
d. update the client’s mental status examination.

Answer 8

c. teach the client strategies to manage postural hypotension.

Question 9

A client diagnosed with major depressive disorder is receiving imipramine 200 mg at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?

a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention

Answer 9

d. Urinary retention

Question 10

A client diagnosed with major depressive disorder tells the nurse, “Bad things that happen are always my fault.” Which response by the nurse will best assist the client to reframe this overgeneralization?

a. “I really doubt that one person can be blamed for all the bad things that happen.”
b. “Let’s look at one bad thing that happened to see if another explanation exists.”
c. “You are being extremely hard on yourself. Try to have a positive focus.”
d. “Are you saying that you don’t have any good things happen?”

Answer 10

b. “Let’s look at one bad thing that happened to see if another explanation exists.”

Question 11

A nurse worked with a client diagnosed with major depressive disorder, severe withdrawal, and psychomotor retardation. After 3 weeks, the client did not improve. The nurse is most at risk for what feelings?

a. guilt and despair.
b. over-involvement.
c. interest and pleasure.
d. ineffectiveness and frustration.

Answer 11

d. ineffectiveness and frustration.

Question 12

A client diagnosed with depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. What information should the nurse provide to the client and family?

a. Need to restrict sodium intake to 1 gram daily.
b. Need to minimize exposure to bright sunlight.
c. Importance of reporting increased suicidal thoughts.
d. Importance of maintaining a tyramine-free diet.

Answer 12

c. Importance of reporting increased suicidal thoughts.

Question 13

A nurse taught a client about a tyramine-restricted diet. Which menu selection would the indicate the client understood the information?

a. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
b. Mashed potatoes, ground beef patty, corn, green beans, apple pie
c. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls

Answer 13

b. Mashed potatoes, ground beef patty, corn, green beans, apple pie

Question 14

What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy (ECT) treatment?

a. Nutrition and hydration
b. Supporting physiological stability
c. Reducing disorientation and confusion
d. Assisting the client to identify and test negative thoughts

Answer 14

b. Supporting physiological stability

Question 15

A nurse provided medication education for a client diagnosed with major depressive disorder who began a new prescription for phenelzine. Which behavior indicates effective learning? The client

a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. can identify foods with high selenium content that should be avoided.
d. confers with a pharmacist when selecting over-the-counter medications.

Answer 15

d. confers with a pharmacist when selecting over-the-counter medications.

Question 16

Major depressive disorder resulted after a client’s employment was terminated. The client now says to the nurse, “I’m not worth the time you spend with me. I am the most useless person in the world.” Which nursing diagnosis applies?

a. Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity

Answer 16

c. Situational low self-esteem

Question 17

A client diagnosed with major depressive disorder does not interact with others except when addressed, and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the client. Which communication technique will be effective?

a. Make observations.
b. Ask the client direct questions.
c. Phrase questions to require yes or no answers.
d. Frequently reassure the client to reduce guilt feelings.

Answer 17

a. Make observations.

Question 18

A client being treated for depression has taken sertraline daily for a year. The client calls the clinic nurse and says, “I stopped taking my antidepressant 2 days ago. Now I am having nausea, nervous feelings, and I can’t sleep.” The nurse will advise the client to:

a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take a dose of your antidepressant now and come to the clinic to see the health care provider.”
d. “Resume taking your antidepressants for 2 more weeks and then discontinue them again.”

Answer 18

c. “Take a dose of your antidepressant now and come to the clinic to see the health care provider.”

Question 19

Which documentation for a client diagnosed with major depressive disorder indicates the treatment plan was effective?

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
b. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure, just like me.”
c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I feel tired all the time.”

Answer 19

a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.

Question 20

A client was diagnosed with seasonal affective disorder (SAD). During which month would this client’s symptoms be most acute?

a. January
b. April
c. June
d. September

Answer 20

a. January

Question 21

A client diagnosed with major depressive disorder repeatedly tells staff, “I have cancer. It’s my punishment for being a bad person.” Diagnostic tests reveal no cancer. What is the priority nursing diagnosis?

a. Powerlessness
b. Risk for suicide
c. Stress overload
d. Spiritual distress

Answer 21

b. Risk for suicide

Question 22

A client diagnosed with major depressive disorder refuses solid foods. In order to meet nutritional needs, which beverage will the nurse offer to this client?

a. Tomato juice
b. Orange juice
c. Hot tea
d. Milk

Answer 22

d. Milk

Question 23

During a psychiatric assessment, the nurse observes a client’s facial expression is without emotion. The client says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How will the nurse document the client’s affect and mood?

a. Affect depressed; mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent.

Answer 23

b. Affect flat; mood depressed

Question 24

A disheveled client in the acute phase of major depressive disorder is withdrawn, has psychomotor retardation, and has not showered for several days. What action will the nurse take?

a. bring up the issue at the community meeting.
b. calmly tell the client, “You must bathe daily.”
c. make observations about the client’s poor personal hygiene.
d. firmly and neutrally assist the client with showering.

Answer 24

d. firmly and neutrally assist the client with showering.

Question 25

A client diagnosed with major depressive disorder began taking escitalopram 5 days ago. The client now says, “This medicine isn’t working.” What is the nurse’s best intervention?

a. discuss with the health care provider the need to increase the dose.
b. reassure the client that the medication will be effective soon.
c. explain the time lag before antidepressants relieve symptoms.
d. critically assess the client for symptoms of improvement.

Answer 25

c. explain the time lag before antidepressants relieve symptoms.

Question 26

A client is experiencing psychomotor agitation associated with major depressive disorder. Which observation presented by the client would the nurse associate with this symptom?

a. pacing aimlessly around the room.
b. asking the nurse to repeat instructions.
c. reporting prickly skin sensations.
d. demonstrating slowed verbal responses.

Answer 26

a. pacing aimlessly around the room.

Question 27

A client diagnosed with major depressive disorder received six electroconvulsive therapy (ECT) sessions and aggressive doses of antidepressant medication. The client owns a small business and was counseled not to make major decisions for a month. What is the correct rationale for this counseling?

a. Antidepressant medications alter catecholamine levels, which impairs decision-making abilities.
b. Antidepressant medications may cause confusion related to limitation of tyramine in the diet.
c. Temporary memory impairments and confusion may occur with ECT.
d. The client needs time to readjust to a pressured work schedule.

Answer 27

c. Temporary memory impairments and confusion may occur with ECT.

Question 28

A nurse instructs a client taking a medication that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of what?

a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock.

Answer 28

b. hypertensive crisis.

Question 29

Transcranial Magnetic Stimulation (TCM) is scheduled for a client diagnosed with major depressive disorder. Which comment by the client indicates teaching about the procedure was effective?

a. “They will put me to sleep during the procedure, so I won’t know what is
happening.”
b. “I might be a little dizzy or have a mild headache after each procedure.”
c. “I will be unable to care for my children for about 2 months.”
d. “I will avoid eating foods that contain tyramine.”

Answer 29

b. “I might be a little dizzy or have a mild headache after each procedure.”

Question 30

The admission note indicates a client diagnosed with major depressive disorder has anergia and anhedonia. For which measures should the nurse plan? (Select all that apply.)

a. Channeling excessive energy
b. Reducing guilty ruminations
c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardatio

Answer 30

c. Instilling a sense of hopefulness
d. Assisting with self-care activities
e. Accommodating psychomotor retardatio

Question 31

A nurse caring for a client diagnosed with major depressive disorder reads in the client’s medical record, “This client shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to this documentation? (Select all that apply.)

a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia

Answer 31

a. Imbalanced nutrition: less than body requirements
c. Sexual dysfunction
d. Self-care deficit
f. Insomnia

Question 32

A client diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? (Select all that apply.)

a. Offer laxatives if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
d. Eliminate all daily caffeine intake.
e. Restrict intake of processed foods.

Answer 32

a. Offer laxatives if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.

Question 33

A client being treated with paroxetine 50 mg po daily reports to the clinic nurse, “I took a few extra tablets earlier today and now I feel bad.” Which assessments are most critical? (Select all that apply.)

a. Vital signs
b. Urinary frequency
c. Psychomotor retardation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness

Answer 33

a. Vital signs
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness