Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A student nurse caring for a depressed patient reads in the patient's medical record: "This patient clearly shows the vegetative signs of depression." What can the student expect to observe?
A. Feelings of hopelessness, helplessness, and worthlessness.
This choice is incorrect. Feelings of hopelessness, helplessness, and worthlessness are psychological symptoms associated with depression but are not categorized as vegetative signs. Vegetative signs of depression primarily involve disruptions in basic bodily functions.
B. Constipation, anorexia, sleep disturbance.
This is the correct choice. Vegetative signs of depression refer to physical symptoms that are related to basic bodily functions. Constipation, anorexia (loss of appetite), and sleep disturbances (such as insomnia) are examples of vegetative signs that often accompany depressive episodes.
C. Anxiety and psychomotor agitation.
This choice is incorrect. Anxiety and psychomotor agitation are emotional and behavioral symptoms of depression but are not considered vegetative signs. Vegetative signs are more focused on disruptions in bodily functions.
D. Suicidal ideation.
This choice is incorrect. Suicidal ideation is a serious and concerning symptom of depression, but it is not classified as a vegetative sign. Vegetative signs are more related to changes in bodily functions rather than specific thoughts or ideation.
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 notices that a client who has moderate anxiety is pacing the hall and mumbling. As the nurse approaches the client, he states, "I am at the end of my rope. I don't think I can take any more bad news." Which of the following responses should the nurse make?
A. "Providers usually recommend relaxation exercises for clients who are as upset as you are.".
Recommending relaxation exercises might not be the most appropriate response in this situation. The client is already exhibiting moderate anxiety and pacing, suggesting a high level of distress. Offering relaxation exercises as a first response might not effectively address the immediate need for support and intervention.
B. "An antianxiety pill works best for situations like this.".
Suggesting an antianxiety pill as the best solution oversimplifies the situation. While medication might be a valid consideration, jumping to this option without further assessment or exploration of the client's feelings could be premature and neglectful of potential underlying concerns.
C. "Come with me to an area where we can talk without interruption.".
This is the correct choice. The nurse's response prioritizes creating a safe and supportive environment for communication. Taking the client to a quieter area demonstrates empathy and acknowledges the client's distress, offering an opportunity to address their concerns without distractions.
D. "Most clients with anxiety issues benefit from lying down.".
Suggesting that most clients benefit from lying down oversimplifies the management of anxiety issues. While rest and relaxation are generally important, it doesn't specifically address the client's immediate distress or provide a suitable avenue for open communication.
When prescribing a tricyclic antidepressant, which patient would we be most concerned about dispensing the medication to?
A. A 30-year-old female who has not responded to 2 other antidepressant medications.
This patient has not responded to two other antidepressant medications, indicating a history of treatment resistance. While this is a concern, the choice of medication should be based on various factors beyond treatment history.
B. A patient with a recent suicide attempt.
This is the correct choice. Tricyclic antidepressants (TCAs) have a high potential for overdose and can be lethal in cases of deliberate self-harm. Dispensing TCAs to a patient with a recent suicide attempt could greatly increase the risk of overdose and potential harm.
C. A 50-year-old male with hyperlipidemia.
Hyperlipidemia, or high cholesterol, is not a primary concern when prescribing tricyclic antidepressants. This choice is less relevant to the immediate safety considerations associated with TCAs.
D. A patient with refractory anxiety.
While a patient with refractory anxiety is an important consideration, the most concerning scenario among the choices is dispensing TCAs to a patient with a recent suicide attempt. The question asks for the patient about whom we would be most concerned, and that is the patient with a recent suicide attempt due to the high risk of overdose with TCAs.
A patient comes to the emergency department with complaints of a headache and vomiting. Upon questioning, the patient says she is taking the drug phenelzine. The nurse should continue the assessment by first asking:.
A. What foods have you been eating?.
This is the correct choice. Phenelzine is a monoamine oxidase inhibitor (MAOI), and patients taking MAOIs need to follow a strict dietary regimen to avoid consuming foods high in tyramine. These foods, such as aged cheeses, cured meats, and certain beverages, can lead to hypertensive crisis when ingested by patients on MAOIs. Therefore, assessing the patient's dietary intake is crucial to ensuring their safety.
B. What dose of phenelzine are you taking?.
Inquiring about the dose of phenelzine is important, but assessing dietary intake takes precedence due to the potential for interactions between certain foods and MAOIs.
C. Do you have flu symptoms?.
Asking about flu symptoms is not directly relevant to the patient's use of phenelzine. The primary concern with phenelzine is its interaction with tyramine-rich foods, not flu symptoms.
D. Tell me about your history of headaches.
While the patient's history of headaches is important, assessing dietary intake is more urgent in this situation. The patient's use of phenelzine requires immediate attention due to the risk of dietary interactions, which can have severe consequences.