Question 1

A depressed patient who is taking a tricyclic antidepressant tells the nurse,"I don't think I can keep taking these pills.They make me very dizzy,especially when I stand up." The best nursing response is:

Accepted Answer

Drowsiness,dizziness,and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants.Postural hypotension can be managed by teaching the patient to stay well hydrated,change positions slowly,and hold on to bedrails or other secure structures to steady oneself until dizziness subsides.Knowing these facts may be enough to convince the patient to continue the medication.Implying that the side effect should be acceptable,that the patient should adjust to it,or that the patient's concern is a result of the depression itself all ignore the potential for reducing the side effect and its consequences (e.g. ,fall risk)via patient education.

Question 2

A depressed patient is receiving imipramine (Tofranil)300 mg daily.Which side effect requires seeking medical attention?

Accepted Answer

All the side effects mentioned are the result of the anticholinergic effects of the drug.Of these,only urinary retention warrants immediate medical attention.Dry mouth,blurred vision,and nasal congestion do not usually develop into serious medical concerns.However,urinary retention can lead to medical complications and intense pain,can be reduced via medication and other interventions,and requires prompt medical intervention.

Question 3

Planned interventions for a newly admitted severely depressed patient should include:

Accepted Answer

Approximately two-thirds of depressed people contemplate suicide.A suicide attempt requires only a short period of unobserved activity.Traditional "every-fifteen-minute checks" allow sufficient time to enact a suicide and are inadequate.Therefore,ongoing direct (but unobtrusive)observation of the depressed patient,at least until such time as his risk for self-harm has been fully assessed,minimizes the chance of self-harm while on the unit.Allowing excessive "alone time" facilitates withdrawal.Rest is important,and while it is not unusual for depressed patients to have a sleep deficit,excessive sleeping is a form of withdrawal,and sleeping at atypical times can further disrupt the patient's circadian rhythm,interfering with sleep in the long run.Impaired cognition,concentration,and self-esteem would make assuming a leadership role unrealistic and frustrating for the patient.

Question 4

A disheveled,severely depressed patient with psychomotor retardation has not showered for several days.The nurse should:

Accepted Answer

Impaired hygiene is common in severe depression.Depressed patients have difficulty organizing tasks involving multiple steps and may avoid them for that reason.They also suffer from anergia (reduced energy)and loss of awareness and interest related to hygiene.It is often necessary for nurses to take an active role in directing the patient into the shower and providing step-by-step instructions to guide the patient and keep him on task.Rewards do not work effectively on people who are anhedonic or feel undeserving (or deserving of punishment).Advising him that he offends his peers would be a disconfirming (nontherapeutic)statement in that it would cause embarrassment and shame,further impairing his self-esteem.Depressed patients are often cognitively disorganized,making it unlikely that they would respond as hoped to generic education about hygiene in a group setting.

Question 5

A woman became severely depressed when the last of her six children moved out of the home 4 months ago.She has withdrawn from others,neglected to care for herself,lost weight,and repeatedly states,"No one cares about me anymore." Before the onset of symptoms she had been gregarious,a meticulous housekeeper,was neatly groomed,and often participated in community activities.Upon admission to the mental health unit,the patient repeatedly tells nursing staff,"No one cares about me.I'm worthless." Which response by the nurse would be most therapeutic?

Accepted Answer

Spending time with the patient at intervals throughout the day shows acceptance by the nurse and will help the patient establish a therapeutic relationship.It also helps counter the withdrawal often seen in depression.Setting definite times for contacts and keeping the appointments shows reliability on the part of the nurse,an element that fosters trust building.Profoundly depressed persons whose self-image is very negative have difficulty accepting that others could care and would tend to believe a nurse who indicates she cares is insincere."Things will look brighter" is trite and a cliché and is also difficult for a profoundly depressed person to imagine and accept.The patient is essentially unable to say positive things at this point,so pointing out that her behavior is causing others to reject her tends to worsen her self-esteem rather than help her change.Also,it is premature to use confrontation during the initial phase of the nurse-patient relationship.

Question 6

A depressed patient does not converse except when addressed,and then only in monosyllables.Which response by the nurse is likely to be most helpful?

Accepted Answer

Alogia or poverty of speech is common in severe depression and other mental health disorders.Making observations about neutral topics such as the environment draws the patient into the reality around him in a nonthreatening way but places no burdensome expectations for answers on the patient.It also helps to convey interest in the patient and helps to build rapport.Acceptance and support are shown by the nurse's presence.Direct questions may make the patient feel that the encounter is an interrogation.Open-ended questions are preferable if the patient is able to participate in dialogue.Decision making is often impaired in depression,so asking the patient what he wants to talk about burdens the patient with a task (decision making)likely to frustrate him because he does not want to talk at all.Telling the patient that more talking is desirable places a burden of unrealistic expectations on the patient;this can increase feelings of guilt,frustration,or worthlessness.

Question 7

A man with severe depression is admitted to the partial hospitalization program for mood disorders after exhibiting unintentional weight loss and refusal to go to work.He does not bathe or shave,sleeps poorly,and repeatedly states: "I'm useless,I'm no good to anyone." Which intervention would be best to include in the patient's initial care plan?

Accepted Answer

In this patient's initial treatment,it is important to focus on basic physiological functioning and safety concerns such as ensuring adequate nutrition.Therefore,interventions focused on basic functioning should be stressed in his initial care plan.Providing finger foods enables easier intake,and nutrient-dense foods require that the patient ingest less food while still maintaining his weight.Severely depressed persons have impaired cognition and would have difficulty with tasks involving concentration or fine motor skills.It is important to choose activities for which the patient would have a high likelihood of success (or a positive experience)in order to reduce failure and reinforcement of negative self-image.Reinforcing an interest in work is desirable but unrealistic for his initial care plan.

Question 8

Information given to a depressed patient and family when the patient begins selective serotonin reuptake inhibitor (SSRI)antidepressant therapy should include the directive to:

Accepted Answer

Some evidence indicates that suicidal ideation may worsen at the beginning of SSRI antidepressant therapy,so close monitoring is necessary,and the patient and family should be directed to report immediately any intensification in suicidal ideation,intent,or plans.SSRI medications do not increase photosensitivity or require dietary tyramine or sodium restrictions.

Question 9

A depressed patient repeatedly tells staff that he's evil and that his "insides are rotting" because God is punishing him.What would the priority nursing diagnosis for this patient be?

Accepted Answer

The patient is demonstrating delusional thinking suggestive of worthlessness and guilt.The delusional thinking indicates significant cognitive disorganization,potentially placing the patient at risk due to impaired judgment.The cognitive disorganization also interferes with patient learning and understanding and would make it more difficult for the patient to respond to interpersonal therapies.If the issue of impaired thought process is not addressed,the patient will have more difficulty responding to other forms of treatment and may experience harm.Therefore,disturbed thought process is the priority concern in this situation.The other diagnoses do not involve issues of risk and thus are lower priorities.

Question 10

A recently divorced man with severe depression exhibits poor sleep and impaired concentration,leading him to function poorly at work.Inattention to hygiene and irritability with others aggravate problems at work.Co-workers do not recognize that he is depressed and instead assume his behavioral changes are due to drug abuse.One day he is fired.Work had been his one remaining source of self-worth.The man presents at the emergency room seeking medication to help him sleep.Which of the following responses would be most important for the triage nurse to take at this time?

Accepted Answer

Approximately two-thirds of depressed people contemplate suicide.Depressed patients who exhibit feelings of worthlessness are at higher risk.Significant losses (divorce and loss of job)and depressed mood are major risk factors for suicide.Suicide should be directly assessed.Seeking further information about his sleep habits and exploring treatment options related to depression are desirable but are not as high a priority at this time as assessing possible risk to self.Advising him that sleep medications are not provided by the emergency room could be seen as further rejection and could lead the patient to terminate the assessment prematurely.

Question 11

A patient who became severely depressed after losing her job tells the nurse that she is not worth the time the nurse spends with her.The patient often mentions that she is "the worst person in the world." On the basis of this data,which nursing diagnosis is most appropriate?

Accepted Answer

The patient's statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Low self-esteem.Insufficient information exists to lead to the other diagnoses offered.

Question 12

Which nursing progress note would most suggest that the treatment plan of a severely depressed and withdrawn patient has been effective?

Accepted Answer

Sleeping 6 uninterrupted hours,actively participating in a group activity,and showing renewed interest in aspects of life previously important to the patient are indicators of progress.In the other choices,the patient attended activities but did not participate and maintained disinterest in food and/or impaired sleep.Patients may falsely deny suicide ideation,so self-reports are not fully reliable indicators,and "no self-harm noted",while desirable,also does not necessarily indicate that the desire to die has passed.

Question 13

A student in the Mood Disorders Clinic states that everything he does is wrong and that nothing he tries ever works.Although he has never failed an exam,he believes he will fail the next one.Based on evidence-based research,which of the following interventions would best address a presentation of this type?

Accepted Answer

Cognitive-behavioral therapy attempts to alter the patient's dysfunctional beliefs by identifying automatic and/or distorted thinking and then questioning it.This is then followed by rewording or reframing the thought in a more realistic manner.The patient is also taught the connection between thoughts and mood.Research shows that cognitive-behavioral therapy involves the formation of new connections between nerve cells in the brain and is at least as effective as medication.Evidence does not support similar effectiveness for the other psychotherapeutic modalities mentioned.

Question 14

A patient became severely depressed when the last of her six children moved out of the home 4 months ago.Since then she has neglected to care for herself,sleeps poorly,lost weight,and repeatedly states,"No one cares about me anymore.I'm not worth anything." Upon admission to the unit,the nursing diagnosis Situational low self-esteem related to feelings of abandonment was established.Which would be an appropriate intermediate outcome for this diagnosis? Patient will:

Accepted Answer

The primary goal of treatment of depression is improved mood,which in turn leads to improvement in other areas of concern such as intake,socialization activity level,and impaired self-esteem.In this case,stating a positive comment about herself would indicate improvement in low self-esteem,and replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome.Agreeing to take medication,while perhaps necessary for her treatment and improvement,would not necessarily indicate improvement in self-esteem and would better serve as a short-term indicator,since it would need to precede other expected outcomes.Interacting with others would be an appropriate intermediate goal for impaired socialization,and identifying factors contributing to her depression would be an appropriate short-term indicator.

Question 15

A patient with a history of heart failure is being assessed by the admitting nurse.Which of the following inquiries by the nurse reflects the research on the connection between heart disease and mental health?

Accepted Answer

Depression has been shown to worsen heart failure,and a variety of cardiac disorders appear to cause depression in some patients.Although anxiety often accompanies any serious medical illness,the special connection between depression and cardiac disease makes this depression the mental health issue meriting special attention in cardiac patients.Heart disease does not have a specific relationship to nightmares.

Question 16

A woman became severely depressed when the last of her six children moved out of the home 4 months ago.Since then she has neglected to care for herself,sleeps poorly,lost weight,and repeatedly states,"No one cares about me anymore.I'm worthless." After hospitalization,the nursing diagnosis of situational low self-esteem related to feelings of abandonment was identified.The nurse wishes to reinforce the patient's self-esteem by acknowledging the improvement in her personal appearance.She's wearing a new dress and has combed her hair.The most appropriate remark would be:

Accepted Answer

Depressed patients usually see the negative side of things,even in positive comments.The meaning of compliments may be altered to "I didn't look nice yesterday" or "They didn't like my other dress." People who do not feel they are attractive may have difficulty trusting others who compliment them,thinking that they are insincere;this can reduce trust in the therapeutic relationship.Neutral comments such as acknowledging the positive changes reinforce the desired behaviors while avoiding negative interpretations.Depressed persons usually have an impaired ability to appreciate humor,so attempts to use humor would not be therapeutic during the initial phase of treatment.

Question 17

A depressed patient who is scheduled to receive electroconvulsive therapy this morning asks the nurse,"How is this treatment supposed to help me?" The best reply would be: "Electroconvulsive therapy seems to ____________."

Accepted Answer

ECT seems to alter neurotransmitter activity,consistent with the biochemical theory of the cause of depression.The other options distort information from other etiological theories and are not supported by research on the mechanism of action of electroconvulsive therapy.

Question 18

A student nurse working with a depressed patient finds herself becoming angry with the patient when he responds slowly or not at all to her efforts to improve his mood.Which explanation most likely explains her emotional response?

Accepted Answer

Although it is true that depressed patients sometimes seem to reject the overtures of staff and seem to resist change despite the nurse's best efforts,the usual cause of negative emotional responses in staff are the staff's own unrealistic expectations.Nursing staff may expect the patient to respond more readily than the patient's depression allows;or they may believe that because the patient is lucid and coherent,he should respond readily and well to verbal interventions.Nurses may also hold unrealistic expectations of themselves,believing that they understand depression because they have been sad themselves and believe their own experiences will be comparable to the patient's (and that what would have been helpful to them will be sufficient to benefit patients as well).However,nursing staff sometimes underestimate how much the depression is affecting the patient's cognition,reasoning,and other higher neurological functions,and when such factors limit the patient's responsiveness,the nurse may experience feelings of anxiety,frustration,incompetence,and even helplessness as a result.Supervision can help the nurse develop realistic expectations for both patient and self.The majority of persons with depression respond well to treatment,showing significant improvement in mood and functioning.It is unlikely that this particular patient is exceptional in failing to respond directly and rapidly to staff's interventions,as most patients improve rather slowly.Depressed patients may resist treatment efforts,but this is not typical of depressed persons.

Question 19

The priority nursing focus for the period immediately after electroconvulsive therapy treatment should be on:

Accepted Answer

During the immediate posttreatment period,the patient is recovering from general anesthesia,hence the need to reestablish and support physiological stability.This includes monitoring the level of consciousness and bodily functions such as vital signs and elimination.Range of motion is unlikely to be affected by ECT and is not a priority.Assessing memory loss immediately after ECT is inappropriate because the patient may be confused.Patients are not more suggestible as a result of ECT.

Question 20

An elderly patient complains bitterly and repetitively about numerous somatic concerns,but he has been examined thoroughly by several different health care providers,and physical examinations suggest that he is in good health.The nurse should suspect that the patient's somatic complaints most likely are:

Accepted Answer

Elderly persons may have difficulty expressing emotions such as sadness or grief and may express them somatically instead.Somatic complaints may be stress related but are not a coping mechanism per se.No data is offered to support the presence of an undiagnosed medical illness or injury.Although aging processes can produce increasing aches and pains,this patient's presentation of bitter,repetitive somatic complaints and negative physical examinations suggests that a different phenomenon is at work.

Quiz 13: Depressive Disorders