RN HESI Case Study - Major Depressive Disorder With Verified
Solutions
Areas of Focus during Initial Assessment
When the nurse is conducting the initial assessment for anxiety, they should prioritize the following
areas that are most characteristic:
- A. Symptoms of restlessness, difficulty concentrating, irritability.
- C. Increasing symptoms of depression with consistently sad, low mood.
- E. Suicidal ideation.
Therapeutic Relationship: Subjective Assessment
In the orientation phase of building a therapeutic relationship, the nurse should use the following
approach to gain subjective information from the client:
- D. "Give me an example of how you feel when you are anxious."
This approach encourages the client to share personal experiences related to their anxiety.
Level of Anxiety in the Client
The nurse assesses that Angelina is experiencing:
- C. Severe anxiety.
This indicates a heightened level of anxiety that requires intervention.
Assessing Suicide Risk
To appropriately assess a client's risk for suicide, the best approach is:
, - D. "Do you have a plan to harm yourself?"
This direct question allows the nurse to gauge the seriousness of the client's thoughts and intentions.
Responding to Client Comments
In response to Angelina's comments regarding her symptoms, the nurse should:
- D. "Tell me more about your chest pain."
This response encourages the client to elaborate on their symptoms, promoting better understanding
and assessment.
Nursing Diagnoses for Care Plan
When developing the client's care plan, the following nursing diagnoses would take priority:
- A. Anxiety (severe).
- B. Ineffective coping.
- E. Risk for self-harm.
These diagnoses address the most pressing issues at hand.
Encouraged Client Behavior
The nurse should encourage Angelina to:
- C. State the sources for present anxiety.
Identifying sources reduces anxiety and aids in the development of coping strategies.
Additional Nursing Diagnosis
Solutions
Areas of Focus during Initial Assessment
When the nurse is conducting the initial assessment for anxiety, they should prioritize the following
areas that are most characteristic:
- A. Symptoms of restlessness, difficulty concentrating, irritability.
- C. Increasing symptoms of depression with consistently sad, low mood.
- E. Suicidal ideation.
Therapeutic Relationship: Subjective Assessment
In the orientation phase of building a therapeutic relationship, the nurse should use the following
approach to gain subjective information from the client:
- D. "Give me an example of how you feel when you are anxious."
This approach encourages the client to share personal experiences related to their anxiety.
Level of Anxiety in the Client
The nurse assesses that Angelina is experiencing:
- C. Severe anxiety.
This indicates a heightened level of anxiety that requires intervention.
Assessing Suicide Risk
To appropriately assess a client's risk for suicide, the best approach is:
, - D. "Do you have a plan to harm yourself?"
This direct question allows the nurse to gauge the seriousness of the client's thoughts and intentions.
Responding to Client Comments
In response to Angelina's comments regarding her symptoms, the nurse should:
- D. "Tell me more about your chest pain."
This response encourages the client to elaborate on their symptoms, promoting better understanding
and assessment.
Nursing Diagnoses for Care Plan
When developing the client's care plan, the following nursing diagnoses would take priority:
- A. Anxiety (severe).
- B. Ineffective coping.
- E. Risk for self-harm.
These diagnoses address the most pressing issues at hand.
Encouraged Client Behavior
The nurse should encourage Angelina to:
- C. State the sources for present anxiety.
Identifying sources reduces anxiety and aids in the development of coping strategies.
Additional Nursing Diagnosis
