Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?
A. Administer prescribed antidepressants.
Administer prescribed antidepressants. Rationale: While administering prescribed antidepressants is an important nursing intervention for managing major depressive disorder, it is not the priority in this scenario. Safety concerns, such as monitoring for self-harm, take precedence over medication administration.
B. Assist with activities of daily living.
Assist with activities of daily living. Rationale: Assisting with activities of daily living is important for overall patient care, but in the context of a client with major depressive disorder, the priority is ensuring their safety and well-being. Monitoring for self-harm or suicidal ideation is of higher priority.
C. Encourage adequate fluid intake.
Encourage adequate fluid intake. Rationale: Encouraging adequate fluid intake is a general nursing intervention that can support the client's physical health. However, it does not directly address the specific needs of a client with major depressive disorder. Safety and psychological well-being are more pressing concerns.
D. Monitor for risk of self-harm.
Monitor for risk of self-harm. Rationale: This is the priority intervention in this scenario. Clients with major depressive disorder are at an increased risk of self-harm and suicide. Monitoring for signs of self-harm, assessing suicidal ideation, and ensuring a safe environment are critical aspects of care for these clients.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom Psych Nursing Spring 2023 Proctored Exam 3. Take the full exam now
Similar Questions
A nurse is caring for a client who has major depressive disorder (MDD). Which of the following findings should the nurse expect?
A. Attention seeking behavior.
Attention seeking behavior is not typically associated with major depressive disorder (MDD). In MDD, individuals often experience a diminished interest or pleasure in most activities, including seeking attention. This is characterized by symptoms such as persistent low mood, loss of interest or pleasure, fatigue, and feelings of worthlessness.
B. Hyperexcitability.
Hyperexcitability is not a hallmark symptom of major depressive disorder (MDD). Rather, individuals with MDD usually experience psychomotor agitation or retardation, which is a slowing down or speeding up of physical and mental processes. This is opposite to hyperexcitability and is evident in symptoms like slowed speech and movement or restlessness.
C. Exaggerated response to stimuli.
Exaggerated response to stimuli is not a characteristic finding in major depressive disorder (MDD). In fact, individuals with MDD often experience anhedonia, which is the inability to experience pleasure from activities that were previously enjoyable. They tend to have a reduced capacity to respond to positive stimuli rather than an exaggerated response.
D. Significant change in weight.
This is the correct answer. Major depressive disorder can often lead to significant changes in weight. Some individuals may experience weight loss due to appetite changes, decreased interest in eating, or disruptions in their eating patterns. On the other hand, some individuals may experience weight gain, often due to emotional eating or seeking comfort through food.
The nurse has a patient who checks and rechecks her home in response to an obsessive thought that her house will burn down. The nurse and the patient explore the likelihood that the house will actually burn. The patient states there is little likelihood of this occurring. This is making use of:.
A. Cognitive restructuring.
Cognitive restructuring involves identifying and changing distorted thought patterns or beliefs that contribute to emotional distress. In this scenario, the nurse and patient are challenging the obsessive thought that the patient's house will burn down. By exploring the likelihood of this thought and examining evidence for and against it, the patient is engaging in cognitive restructuring. This technique is commonly used in cognitive-behavioral therapy (CBT) to help individuals with obsessive-compulsive disorder (OCD) and other anxiety disorders reframe their thoughts and reduce distress.
B. Desensitization.
Desensitization, also known as systematic desensitization, is a technique used in exposure therapy to treat anxiety disorders. It involves gradually exposing the individual to the feared object or situation while teaching relaxation techniques to reduce anxiety. In this scenario, the focus is on assessing the likelihood of the thought rather than exposing the patient to the feared situation, so desensitization is not the correct choice.
C. Flooding.
Flooding is another technique used in exposure therapy. It involves exposing the individual to the feared situation at full intensity, without any gradual buildup. The goal is to extinguish the conditioned fear response by experiencing the feared situation without any actual harm occurring. Since the scenario involves assessing the likelihood of the obsessive thought, and not directly exposing the patient to the fear, flooding is not the appropriate choice.
D. Relaxation technique.
Relaxation technique is not the correct choice in this scenario. While relaxation techniques can be beneficial in managing anxiety and stress, the main focus of the situation is on addressing the obsessive thought and its associated distress through cognitive restructuring. Relaxation techniques might be used as part of a broader treatment plan, but they are not the central technique being used here.
A patient who is a recovering alcoholic has been diagnosed as having panic disorder. The psychiatrist is planning long-term treatment with a medication that is taken daily. Which medication should the nurse anticipate to plan for patient teaching?
A. Chlorpromazine.
Chlorpromazine. Rationale: Chlorpromazine is an antipsychotic medication primarily used to manage psychotic disorders such as schizophrenia, not panic disorder. It has a different mechanism of action and is not suitable for long-term treatment of panic disorder.
B. Paroxetine.
Paroxetine. Rationale: Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for panic disorder and other anxiety disorders. SSRIs are considered first-line treatment options due to their effectiveness in managing anxiety symptoms and lower risk of dependence compared to benzodiazepines like alprazolam.
C. Propranolol.
Propranolol. Rationale: Propranolol is a beta-blocker often used to manage physical symptoms of anxiety, such as tremors and rapid heart rate. While it can be helpful in certain anxiety situations, it is not a primary medication for panic disorder. SSRIs like paroxetine are more suitable for long-term treatment of panic disorder.
D. Alprazolam.
Alprazolam. Rationale: Alprazolam is a short-acting benzodiazepine used to treat acute symptoms of anxiety and panic. However, it is associated with a risk of dependence and is generally not recommended for long-term treatment. SSRIs like paroxetine are preferred due to their better safety profile and effectiveness in preventing panic attacks over the long term.
E. Alprazolam. A patient who is a recovering alcoholic has been diagnosed as having panic disorder. The psychiatrist is planning long-term treatment with a medication that is taken daily. Which medication should the nurse anticipate to plan for patient teaching?.