A 75-year-old client diagnosed with a long history of depression is currently
on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for
hypertension and is recovering from the flu. Which nursing diagnosis
should the nurse assign highest priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostatic hypotension
D. Risk for infection R/T suppressed white blood cell count
ANS: C
A side effect of Sinequan is orthostatic hypotension. Dehydration due to
fluid loss from a combination of diuretic medication and flu symptoms can
also contribute to this problem, putting this client at risk for injury R/T
orthostatic hypotension.
A client admitted to the psychiatric unit following a suicide attempt is
diagnosed with major depressive disorder. Which behavioral symptoms
should the nurse expect to assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Expressions of poor self-esteem
ANS: B
Lack of attention to grooming and hygiene is the only behavioral symptom
presented. Depressed clients do not care enough about themselves to
participate in grooming and hygiene.
,A client diagnosed with major depressive disorder was raised in an
excessively religiously based household. Which nursing intervention would
be most appropriate to address this client's underlying problem?
A. Encourage the client to bring into awareness underlying sources of guilt.
B. Teach the client that religious beliefs should be put into perspective
throughout the life span.
C. Confront the client with the irrational nature of the belief system.
D. Assist the client to modify his or her belief system in order to improve
coping skills.
ANS: A
A client raised in an excessively religiously based household maybe at risk
for experiencing guilt to the point of accepting liability in situations for
which one is not responsible. The client may view himself or herself as evil
and deserving of punishment leading to depression. Assisting the client to
bring these feelings into awareness allows the client to realistically appraise
distorted responsibility and dysfunctional guilt.
, A client diagnosed with seasonal affective disorder (SAD) states, "I've been
feeling 'down' for 3 months. Will I ever feel like myself again?" Which
reply by the nurse will best assess this client's symptoms.
A. "Have you been diagnosed with any physical disorder within the last 3
months?"
B. "Have you experienced any traumatic events that triggered this mood
change?"
C. "People who have seasonal mood changes often feel better when spring
comes."
D. "Help me understand what you mean when you say, 'feeling down'?"
ANS: D
The nurse is using a clarifying statement in order to gather more details
related to this client's mood. The diagnosis of SAD is not associated with a
traumatic event.
A client is admitted to the psychiatric unit with a diagnosis of major
depression. The client is unable to concentrate, has no appetite, and is
experiencing insomnia. Which should be included in this client's plan of
care?
A. A simple, structured daily schedule with limited choices of activities
B. A daily schedule filled with activities to promote socialization
C. A flexible schedule that allows the client opportunities for decision
making
D. A schedule that includes mandatory activities to decrease social isolation
ANS: A
A client diagnosed with depression has difficulty concentrating and may be
overwhelmed by activity overload or the expectation of independent
decision making. A simple, structured daily schedule with limited choices of
activities is more appropriate.
on doxepin (Sinequan) 100 mg daily. The client takes a daily diuretic for
hypertension and is recovering from the flu. Which nursing diagnosis
should the nurse assign highest priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostatic hypotension
D. Risk for infection R/T suppressed white blood cell count
ANS: C
A side effect of Sinequan is orthostatic hypotension. Dehydration due to
fluid loss from a combination of diuretic medication and flu symptoms can
also contribute to this problem, putting this client at risk for injury R/T
orthostatic hypotension.
A client admitted to the psychiatric unit following a suicide attempt is
diagnosed with major depressive disorder. Which behavioral symptoms
should the nurse expect to assess?
A. Anxiety and unconscious anger
B. Lack of attention to grooming and hygiene
C. Guilt and indecisiveness
D. Expressions of poor self-esteem
ANS: B
Lack of attention to grooming and hygiene is the only behavioral symptom
presented. Depressed clients do not care enough about themselves to
participate in grooming and hygiene.
,A client diagnosed with major depressive disorder was raised in an
excessively religiously based household. Which nursing intervention would
be most appropriate to address this client's underlying problem?
A. Encourage the client to bring into awareness underlying sources of guilt.
B. Teach the client that religious beliefs should be put into perspective
throughout the life span.
C. Confront the client with the irrational nature of the belief system.
D. Assist the client to modify his or her belief system in order to improve
coping skills.
ANS: A
A client raised in an excessively religiously based household maybe at risk
for experiencing guilt to the point of accepting liability in situations for
which one is not responsible. The client may view himself or herself as evil
and deserving of punishment leading to depression. Assisting the client to
bring these feelings into awareness allows the client to realistically appraise
distorted responsibility and dysfunctional guilt.
, A client diagnosed with seasonal affective disorder (SAD) states, "I've been
feeling 'down' for 3 months. Will I ever feel like myself again?" Which
reply by the nurse will best assess this client's symptoms.
A. "Have you been diagnosed with any physical disorder within the last 3
months?"
B. "Have you experienced any traumatic events that triggered this mood
change?"
C. "People who have seasonal mood changes often feel better when spring
comes."
D. "Help me understand what you mean when you say, 'feeling down'?"
ANS: D
The nurse is using a clarifying statement in order to gather more details
related to this client's mood. The diagnosis of SAD is not associated with a
traumatic event.
A client is admitted to the psychiatric unit with a diagnosis of major
depression. The client is unable to concentrate, has no appetite, and is
experiencing insomnia. Which should be included in this client's plan of
care?
A. A simple, structured daily schedule with limited choices of activities
B. A daily schedule filled with activities to promote socialization
C. A flexible schedule that allows the client opportunities for decision
making
D. A schedule that includes mandatory activities to decrease social isolation
ANS: A
A client diagnosed with depression has difficulty concentrating and may be
overwhelmed by activity overload or the expectation of independent
decision making. A simple, structured daily schedule with limited choices of
activities is more appropriate.
