When assessing a female client who is receiving tricyclic antidepressant therapy, which of the following would alert the nurse to the possibility that the client is experiencing anticholinergic effects?
Anticholinergic effects, which result from blockage of the parasympathetic (craniosacral) nervous system including urine retention, blurred vision, dry mouth & constipation.
John has been hospitalized for major depression and suicidal ideation. Which of the following statements indicates to the nurse that the client is improving?
The statement “I don’t think about killing myself as much as I used to.” Indicates a lessening of suicidal ideation and improvement in the client’s condition.
For a male client with dysthymic disorder, which of the following approaches would the nurse expect to implement?
Dysthymia is a less severe, chronic depression diagnosed when a client has had a depressed mood for more days than not over a period of at least 2 years. Client with dysthymic disorder benefit from psychotherapeutic approaches that assist the client in reversing the negative self-image, negative feelings about the future.
Nurse Tony should first discuss terminating the nurse-client relationship with a client during the:
When the nurse and client agree to work together, a contract should be established, the length of the relationship should be discussed in terms of its ultimate termination.
Malou is diagnosed with major depression spends majority of the day lying in bed with the sheet pulled over his head. Which of the following approaches by the nurse would be the most therapeutic?
The nurse should initiate brief, frequent contacts throughout the day to let the client know that he is important to the nurse. This will positively affect the client’s self-esteem.
Joe who is very depressed exhibits psychomotor retardation, a flat affect and apathy. The nurse in charge observes Joe to be in need of grooming and hygiene. Which of the following nursing actions would be most appropriate?
The client with depression is preoccupied, has decreased energy, and is unable to make decisions. The nurse presents the situation, “It’s time for a shower”, and assists the client with personal hygiene to preserve his dignity and self-esteem.
When assessing a male client for suicidal risk, which of the following methods of suicide would the nurse identify as most lethal?
A crucial factor is determining the lethality of a method is the amount of time that occurs between initiating the method & the delivery of the lethal impact of the method.
When teaching Mario with a typical depression about foods to avoid while taking phenelzine(Nardil), which of the following would the nurse in charge include?
Foods high in tyramine, those that are fermented, pickled, aged, or smoked must be avoided because when they are ingested in combination with MAOIs a hypertensive crisis will occur.
Danny who is diagnosed with bipolar disorder and acute mania, states the nurse, “Where is my daughter? I love Louis. Rain, rain go away. Dogs eat dirt.” The nurse interprets these statements as indicating which of the following?
Flight of ideas is speech pattern of rapid transition from topic to topic, often without finishing one idea. It is common in mania.
Terry with mania is skipping up and down the hallway practically running into other clients. Which of the following activities would the nurse in charge expect to include in Terry’s plan of care?
The client with mania is very active & needs to have this energy channeled in a constructive task such as cleaning or tidying the room.
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