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A priority nursing intervention for a patient diagnosed with major depressive
disorder is:
a. distracting the patient from self-absorption.
b. carefully and inconspicuously observing the patient around the clock.
C. allowing the patient to spend long periods alone in self-reflection.
D. offering opportunities for the patient to assume a leadership role in the
therapeutic milieu. - ✔✔b. carefully and inconspicuously observing the patient
around the clock.
Approximately two thirds of people with depression contemplate suicide.
Patients with depression who exhibit feelings of worthlessness are at higher
risk. Regularly planned observations of the patient with depression may prevent
a suicide attempt on the unit.
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,A patient diagnosed with major depressive disorder repeatedly tells staff
members, I have cancer. Its my punishment for being a bad person. Diagnostic
tests reveal no cancer. Select the priority nursing diagnosis.
a. Powerlessness
b. Risk for suicide
c. Stress overload
d. Spiritual distress - ✔✔b. Risk for suicide
A patient with depression who feels so worthless as to believe cancer is
deserved is at risk for suicide. Safety concerns take priority over the other
diagnoses listed.
A patient was started on escitalopram (Lexapro) 5 days ago and now says, This
medicine isn't working. The nurses best intervention would be to:
a. discuss with the health care provider the need to change medications.
b. reassure the patient that the medication will be effective soon.
C. explain the time lag before antidepressants relieve symptoms.
D. critically assess the patient for symptom relief. - ✔✔C. explain the time lag
before antidepressants relieve symptoms.
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,Escitalopram is an SSRI antidepressant. Between 1 and 3 weeks of treatment are
usually necessary before a relief of symptoms occurs. This information is
important to share with patients.
The admission note indicates a patient 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 retardation - ✔✔C,D,E
Anhedonia refers to the inability to find pleasure or meaning in life; thus
planning should include measures to accommodate psychomotor retardation,
assist with activities of daily living, and instill hopefulness. Anergia is the lack of
energy, not excessive energy. Anhedonia does not necessarily imply the
presence of guilty ruminations.
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, A patient has been prescribed a selective serotonin reuptake inhibitor (SSRI)
antidepressant. After taking the new medication, the patient states, This
medication isn't working. I don't feel any different. What is the best response by
the nurse?
a.
I will call your care provider. Perhaps you need a different medication.
b.
Don't worry. You can try taking it at a different time of day to help it work
better.
c.
It usually takes a few weeks for you to notice improvement from this
medication.
d.
Your life is much better now. You will feel better soon. - ✔✔c.
It usually takes a few weeks for you to notice improvement from this
medication
Seeing a response to antidepressants takes 3 to 6 weeks. No change in
medications is indicated at this point of treatment because there is no report of
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