Mood Disorders: Depression

MULTIPLE CHOICE

1. A patient became severely depressed when the last of six children moved out of the home 4 months ago. The patient repeatedly says, “No one cares about me. I’m not worth anything.” Which response by the nurse would be the most helpful?
a. “Things will look brighter soon. Everyone feels down once in a while.”
b. “The staff here cares about you and wants to try to help you get better.”
c. “It is difficult for others to care about you when you repeatedly say negative things about yourself.”
d. “I’ll sit with you for 10 minutes now and return for 10 minutes at lunchtime and again at 2:30 this afternoon.”
ANS: D
Spending time with the patient at intervals throughout the day shows acceptance by the nurse and helps the patient establish a relationship with the nurse. The therapeutic technique is called offering self. Setting definite times for the therapeutic contacts and keeping the appointments show predictability on the part of the nurse, an element that fosters the building of trust. The incorrect responses would be difficult for a person with profound depression to believe, provide trite reassurance, and are counterproductive. The patient is unable to say positive things at this point.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 260-261 | Pages: 263-264 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

2. A patient became depressed after the last of six children moved out of the home 4 months ago. The patient has been self-neglectful, slept poorly, lost weight, and repeatedly says, “No one cares about me anymore. I’m not worth anything.” Select an appropriate initial outcome for the nursing diagnosis: Situational low self-esteem, related to feelings of abandonment. The patient will:
a. verbalize realistic positive characteristics about self by (date) .
b. consent to take antidepressant medication regularly by (date) .
c. initiate social interaction with another person daily by (date) .
d. identify two personal behaviors that alienate others by (date) .
ANS: A
Low self-esteem is reflected by making consistently negative statements about self and self-worth. Replacing negative cognitions with more realistic appraisals of self is an appropriate intermediate outcome. The incorrect options are not as clearly related to the nursing diagnosis. Outcomes are best when framed positively; identifying two personal behaviors that might alienate others is a negative concept.

DIF: Cognitive Level: Application (Applying) REF: Page: 247 | Page: 259
TOP: Nursing Process: Outcomes Identification
MSC: NCLEX: Psychosocial Integrity

3. A nurse wants to reinforce positive self-esteem for a patient diagnosed with major depressive disorder. Today, the patient is wearing a new shirt and has neat, clean hair. Which remark is most appropriate?
a. “You look nice this morning.”
b. “You are wearing a new shirt.”
c. “I like the shirt you’re wearing.”
d. “You must be feeling better today.”
ANS: B
Patients with depression usually see the negative side of things. The meaning of compliments may be altered to “I didn’t look nice yesterday” or “They didn’t like my other shirt.” Neutral comments such as an observation avoid negative interpretations. Saying “You look nice” or “I like your shirt” gives approval (nontherapeutic techniques). Saying “You must be feeling better today” is an assumption, which is nontherapeutic.

DIF: Cognitive Level: Application (Applying)
REF: Pages: 259-261 | Pages: 263-264 TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity

4. An adult diagnosed with major depressive disorder was treated with medication and cognitive behavioral therapy. The patient now recognizes how passivity contributed to the depression. Which intervention should the nurse suggest?
a. Social skills training
b. Relaxation training classes
c. Use of complementary therapy
d. Learning desensitization techniques
ANS: A
Social skills training is helpful in treating and preventing the recurrence of depression. Training focuses on assertiveness and coping skills that lead to positive reinforcement from others and the development of a patient’s support system. The use of complementary therapy refers to adjunctive therapies such as herbals. Assertiveness would be of greater value than relaxation training because passivity is a concern. Desensitization is used in the treatment of phobias.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 259-261
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

5. 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.
ANS: B
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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 255 | Pages: 259-260
TOP: Nursing Process: Planning MSC: NCLEX: Safe, Effective Care Environment

6. When counseling patients diagnosed with major depressive disorder, an advanced practice nurse will address the negative thought patterns by using:
a. psychoanalytic therapy.
b. desensitization therapy.
c. cognitive behavioral therapy.
d. alternative and complementary therapies.
ANS: C
Cognitive behavioral therapy attempts to alter the patient’s dysfunctional beliefs by focusing on positive outcomes rather than negative attributions. The patient is also taught the connection between thoughts and resultant feelings. Research shows that cognitive behavioral therapy involves the formation of new connections among nerve cells in the brain and that it is at least as effective as medication. Evidence does not support superior outcomes for the other psychotherapeutic modalities mentioned.

DIF: Cognitive Level: Application (Applying) REF: Pages: 261-262
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

7. A patient says to the nurse, “My life does not have any happiness in it anymore. I once enjoyed holidays, but now they’re just another day.” How would the nurse document the complaint?
a. Vegetative symptom
b. Anhedonia
c. Euphoria
d. Anergia
ANS: B
Anhedonia is a common finding in many types of depression and refers to feelings of a loss of pleasure in formerly pleasurable activities. Vegetative symptoms refer to somatic changes associated with depression. Euphoria refers to an elated mood. Anergia means without energy.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 255
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

8. A patient diagnosed with major depressive disorder is taking a tricyclic antidepressant. The patient says, “I don’t think I can keep taking these pills. They make me so dizzy, especially when I stand up.” The nurse should:
a. explain how to manage postural hypotension, and educate the patient that side effects go away after several weeks.
b. tell the patient that the side effects are a minor inconvenience compared with the feelings of depression.
c. withhold the drug, force oral fluids, and notify the health care provider to examine the patient.
d. teach the patient how to use pursed-lip breathing.
ANS: A
Drowsiness, dizziness, and postural hypotension usually subside after the first few weeks of therapy with tricyclic antidepressants. Postural hypotension can be managed by teaching the patient to stay well hydrated and rise slowly. Knowing these facts may be enough to convince the patient to remain medication compliant. The minor inconvenience of side effects as compared with feelings of depression is a convincing reason to remain on the medication. Withholding the drug, forcing oral fluids, and having the health care provider examine the patient are unnecessary steps. Independent nursing action is appropriate. Pursed-lip breathing is irrelevant.

DIF: Cognitive Level: Application (Applying) REF: Pages: 265-267
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. A patient diagnosed with major depressive disorder is receiving imipramine (Tofranil) 200 mg every night at bedtime. Which assessment finding would prompt the nurse to collaborate with the health care provider regarding potentially hazardous side effects of this drug?
a. Dry mouth
b. Blurred vision
c. Nasal congestion
d. Urinary retention
ANS: D
All the side effects mentioned are the result of the anticholinergic effects of the drug. Only urinary retention and severe constipation warrant immediate medical attention. Dry mouth, blurred vision, and nasal congestion may be less troublesome as therapy continues.

DIF: Cognitive Level: Application (Applying) REF: Page: 266
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

10. A patient diagnosed with major depressive disorder tells the nurse, “Bad things that happen are always my fault.” To assist the patient in reframing this overgeneralization, the nurse should respond:
a. “I really doubt that one person can be blamed for all the bad things that happen.”
b. “Let’s look at one bad thing that happened to see if another explanation exists.”
c. “You are being exceptionally hard on yourself when you say those things.”
d. “How does your belief in fate relate to your cultural heritage?”
ANS: B
By questioning a faulty assumption, the nurse can help the patient look at the premise more objectively and reframe it as a more accurate representation of fact. The incorrect responses are judgmental, irrelevant to an overgeneralization, and cast doubt without requiring the patient to evaluate the statement.

DIF: Cognitive Level: Application (Applying) REF: Page: 261 | Pages: 263-264
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

11. A nurse worked with a patient diagnosed with major depressive disorder who was severely withdrawn and dependent on others. After 3 weeks, the patient did not improve. The nurse is at risk for feelings of:
a. overinvolvement.
b. guilt and despair.
c. interest and pleasure.
d. ineffectiveness and frustration.
ANS: D
Nurses may have expectations for self and patients that are not wholly realistic, especially regarding the patient’s progress toward health. Unmet expectations result in feelings of ineffectiveness, anger, or frustration. Guilt and despair might be observed when the nurse experiences feelings about patients because of sympathy. Interest is possible but not the most likely result. The correct response is more global than overinvolvement.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 258
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

12. A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to:
a. avoid exposure to bright sunlight.
b. report increased suicidal thoughts.
c. restrict sodium intake to 1 g daily.
d. maintain a tyramine-free diet.
ANS: B
Some evidence indicates that suicidal ideation may worsen at the beginning of antidepressant therapy; thus close monitoring is necessary. Avoiding exposure to bright sunlight and restricting sodium intake are unnecessary. Tyramine restriction is associated with monoamine oxidase inhibitor (MAOI) therapy.

DIF: Cognitive Level: Application (Applying) REF: Page: 265 | Page: 270
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. A nurse teaching a patient about a tyramine-restricted diet would approve which meal?
a. Mashed potatoes, ground beef patty, corn, green beans, apple pie
b. Avocado salad, ham, creamed potatoes, asparagus, chocolate cake
c. Macaroni and cheese, hot dogs, banana bread, caffeinated coffee
d. Noodles with cheddar cheese sauce, smoked sausage, lettuce salad, yeast rolls
ANS: A
The correct answer describes a meal that contains little tyramine. Vegetables and fruits contain little or no tyramine, and fresh ground beef and apple pie should be safe. The other meals contain various amounts of tyramine-rich foods or foods that contain vasopressors: avocados, ripe bananas (banana bread), sausages and hot dogs, smoked meat (ham), cheddar cheese, yeast, caffeine drinks, and chocolate.

DIF: Cognitive Level: Application (Applying) REF: Page: 272
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

14. What is the focus of priority nursing interventions for the period immediately after electroconvulsive therapy treatment?
a. Supporting physiologic stability
b. Reducing disorientation and confusion
c. Monitoring pupillary responses
d. Assisting the patient to identify and test negative thoughts
ANS: A
During the immediate post-treatment period, the patient is recovering from general anesthesia, hence the need to establish and support physiologic stability. Monitoring pupillary responses is not a priority. Reducing disorientation and confusion is an acceptable intervention but not the priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.

DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

15. A nurse provided medication education for a patient who takes phenelzine (Nardil) for depression. Which behavior indicates effective learning? The patient:
a. monitors sodium intake and weight daily.
b. wears support stockings and elevates the legs when sitting.
c. consults the pharmacist when selecting over-the-counter medications.
d. can identify foods with high selenium content, which should be avoided.
ANS: C
Over-the-counter medicines may contain vasopressor agents or tyramine, a substance that must be avoided when the patient takes MAOI antidepressants. Medications for colds, allergies, or congestion or any preparation that contains ephedrine or phenylpropanolamine may precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need for sodium limitation, support stockings, or leg elevation. MAOIs interact with tyramine-containing foods, not selenium, to produce dangerously high blood pressure.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 270-271 | Page: 273
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity

16. A patient’s employment is terminated and major depressive disorder results. The patient says to the nurse, “I’m not worth the time you spend with me. I’m the most useless person in the world.” Which nursing diagnosis applies?
a. Powerlessness
b. Defensive coping
c. Situational low self-esteem
d. Disturbed personal identity
ANS: C
The patient’s statements express feelings of worthlessness and most clearly relate to the nursing diagnosis of Situational low self-esteem. Insufficient information exists to justify the other diagnoses.

DIF: Cognitive Level: Application (Applying) REF: Page: 259
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

17. A patient diagnosed with major depressive disorder does not interact with others except when addressed and then only in monosyllables. The nurse wants to show nonjudgmental acceptance and support for the patient. Select the nurse’s most effective approach to communication.
a. Make observations.
b. Ask the patient direct questions.
c. Phrase questions to require “yes” or “no” answers.
d. Frequently reassure the patient to reduce guilt feelings.
ANS: A
Making observations about neutral topics such as the environment draws the patient into the reality around him or her but places no burdensome expectations on the patient for answers. Acceptance and support are shown by the nurse’s presence. Direct questions may make the patient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.

DIF: Cognitive Level: Application (Applying) REF: Pages: 260-261
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

18. A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, “I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, and nightmares.” The nurse should advise the patient:
a. “Go to the nearest emergency department immediately.”
b. “Do not to be alarmed. Take two aspirin and drink plenty of fluids.”
c. “Take one dose of the antidepressant. Come to the clinic to see the health care provider.”
d. “Resume taking the antidepressant for 2 more weeks, and then discontinue it again.”
ANS: C
The patient has symptoms associated with abrupt withdrawal of the tricyclic antidepressant. Taking a dose of the drug will ameliorate the symptoms. Seeing the health care provider will allow the patient to discuss the advisability of going off the medication and to be given a gradual withdrawal schedule if discontinuation is the decision. This situation is not a medical emergency, although it calls for medical advice. Resuming taking the antidepressant for 2 more weeks and then discontinuing again would produce the same symptoms the patient is experiencing.

DIF: Cognitive Level: Application (Applying) REF: Pages: 265-267
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

19. Which documentation indicates the treatment plan of a patient diagnosed with major depressive disorder was effective?
a. Slept 6 hours uninterrupted. Sang with activity group. Anticipates seeing grandchild.
b. Slept 10 hours uninterrupted. Attended craft group; stated “project was a failure, just like me.”
c. Slept 5 hours with brief interruptions. Personal hygiene adequate with assistance. Weight loss of 1 pound.
d. Slept 7 hours uninterrupted. Preoccupied with perceived inadequacies. States, “I feel tired all the time.”
ANS: A
Sleeping 6 hours, participating in a group activity, and anticipating an event are all positive happenings. All the other options show at least one negative finding.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 275
TOP: Nursing Process: Evaluation MSC: NCLEX: Psychosocial Integrity

20. A woman gave birth to a healthy newborn 1 month ago. The patient now reports she cannot cope and is unable to sleep or eat. She says, “I feel like a failure. This baby is the root of my problems.” The priority nursing diagnosis is:
a. Insomnia
b. Ineffective coping
c. Situational low self-esteem
d. Risk for other-directed violence
ANS: D
When a new mother develops depression with a postpartum onset, ruminations or delusional thoughts about the infant often occur. The risk for harming the infant is increased; thus, it becomes the priority diagnosis. The other diagnoses are relevant but are of lower priority.

DIF: Cognitive Level: Application (Applying) REF: Page: 253
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Health Promotion and Maintenance

21. A patient diagnosed with major depressive disorder repeatedly tells staff members, “I have cancer. It’s 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
ANS: B
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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 255 | Page: 259
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

22. Which beverage should the nurse offer to a patient diagnosed with major depressive disorder who refuses solid food?
a. Tomato juice
b. Orange juice
c. Hot tea
d. Milk
ANS: D
Milk is the only beverage listed that provides protein, fat, and carbohydrates. In addition, milk is fortified with vitamins.

DIF: Cognitive Level: Application (Applying) REF: Page: 262
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

23. During a psychiatric assessment, the nurse observes a patient’s facial expressions that are without emotion. The patient says, “Life feels so hopeless to me. I’ve been feeling sad for several months.” How should the nurse document the patient’s affect and mood?
a. Affect depressed; mood flat
b. Affect flat; mood depressed
c. Affect labile; mood euphoric
d. Affect and mood are incongruent
ANS: B
Mood is a person’s self-reported emotional feeling state. Affect is the emotional feeling state that is outwardly observable by others.

DIF: Cognitive Level: Application (Applying) REF: Pages: 255-257
TOP: Nursing Process: Assessment MSC: NCLEX: Psychosocial Integrity

24. A disheveled patient with severe depression and psychomotor retardation has not bathed for several days. The nurse should:
a. avoid forcing the issue.
b. bring up the issue at the community meeting.
c. calmly tell the patient, “You must bathe daily.”
d. firmly and neutrally assist the patient with showering.
ANS: D
When patients are unable to perform self-care activities, staff members must assist them rather than ignore the issue. Better grooming increases self-esteem. Calmly telling the patient to bathe daily and bringing up the issue at a community meeting are punitive.

DIF: Cognitive Level: Application (Applying) REF: Pages: 260-262
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

25. A patient was started on escitalopram (Lexapro) 5 days ago and now says, “This medicine isn’t working.” The nurse’s 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.
ANS: C
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.

DIF: Cognitive Level: Analysis (Analyzing) REF: Pages: 267-270
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

26. A nurse is caring for a patient with low self-esteem. Which nonverbal communication should the nurse anticipate?
a. Arms crossed
b. Staring at the nurse
c. Smiling inappropriately
d. Eyes pointed downward
ANS: D
Nonverbal communication is usually considered more powerful than verbal communication. Downward-casted eyes suggest feelings of worthlessness or hopelessness.

DIF: Cognitive Level: Application (Applying) REF: Page: 260
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

27. A patient diagnosed with major depressive disorder was hospitalized for 8 days. Treatment included six electroconvulsive therapy sessions and aggressive dose adjustments of antidepressant medications. The patient owns a small business and was counseled not to make major decisions for a month. Select the correct rationale for this counseling.
a. Temporary memory impairments and confusion can be associated with electroconvulsive therapy.
b. Antidepressant medications alter catecholamine levels, which impair decision-making abilities.
c. Antidepressant medications may cause confusion related to a limitation of tyramine in the diet.
d. The patient needs time to reorient himself or herself to a pressured work schedule.
ANS: A
Recent memory impairment or confusion or both are often present during and for a short time after electroconvulsive therapy. An inappropriate business decision might be made because of forgotten and important details. The incorrect responses contain rationales that are untrue. The patient needing time to reorient himself or herself to a pressured work schedule is less relevant than the correct rationale.

DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

28. A nurse instructs a patient taking a drug that inhibits the action of monoamine oxidase (MAO) to avoid certain foods and drugs because of the risk of:
a. hypotensive shock.
b. hypertensive crisis.
c. cardiac dysrhythmia.
d. cardiogenic shock.
ANS: B
Patients taking MAOIs must be on a tyramine-free diet to prevent hypertensive crisis. In the presence of MAOIs, tyramine is not destroyed by the liver and, in high levels, produces intense vasoconstriction, resulting in elevated blood pressure.

DIF: Cognitive Level: Comprehension (Understanding) REF: Page: 271
TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. 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
ANS: 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.

DIF: Cognitive Level: Application (Applying) REF: Pages: 255-264
TOP: Nursing Process: Planning MSC: NCLEX: Psychosocial Integrity

2. A student nurse caring for a patient diagnosed with major depressive disorder reads in the patient’s medical record, “This patient shows vegetative signs of depression.” Which nursing diagnoses most clearly relate to the vegetative signs? Select all that apply.
a. Imbalanced nutrition: less than body requirements
b. Chronic low self-esteem
c. Sexual dysfunction
d. Self-care deficit
e. Powerlessness
f. Insomnia
ANS: A, C, D, F
Vegetative signs of depression are alterations in the body processes necessary to support life and growth, such as eating, sleeping, elimination, and sexual activity. These diagnoses are more closely related to vegetative signs than to diagnoses associated with feelings about self.

DIF: Cognitive Level: Application (Applying) REF: Pages: 258-259
TOP: Nursing Process: Diagnosis| Nursing Process: Analysis
MSC: NCLEX: Psychosocial Integrity

3. A patient diagnosed with major depressive disorder will begin electroconvulsive therapy tomorrow. Which interventions are routinely implemented before the treatment? Select all that apply.
a. Administer pretreatment medication 30 to 45 minutes before treatment.
b. Withhold food and fluids for a minimum of 6 hours before treatment.
c. Remove dentures, glasses, contact lenses, and hearing aids.
d. Restrain the patient in bed with padded limb restraints.
e. Assist the patient to prepare an advance directive.
ANS: A, B, C
The correct interventions reflect routine electroconvulsive therapy preparation, which is similar to preoperative preparation: sedation and anticholinergic medication before anesthesia, maintaining nothing-by-mouth status to prevent aspiration during and after treatment, airway maintenance, and general safety by removing prosthetic devices. Restraint is not part of the pretreatment protocol. An advance directive is prepared independent of this treatment.

DIF: Cognitive Level: Application (Applying) REF: Pages: 271-273
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

4. A patient diagnosed with major depressive disorder shows vegetative signs of depression. Which nursing actions should be implemented? Select all that apply.
a. Offer laxatives, if needed.
b. Monitor food and fluid intake.
c. Provide a quiet sleep environment.
d. Eliminate all daily caffeine intake.
e. Restrict the intake of processed foods.
ANS: A, B, C
The correct options promote a normal elimination pattern. Although excessive intake of stimulants such as caffeine may make the patient feel jittery and anxious, small amounts may provide useful stimulation. No indication exists that processed foods should be restricted.

DIF: Cognitive Level: Application (Applying) REF: Pages: 258-259 | Page: 262
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity

5. A patient being treated with paroxetine (Paxil) 50 mg/day orally for major depressive disorder reports to the clinic nurse, “I took a few extra tablets earlier in the day and now I feel bad.” Which aspects of the nursing assessment are most critical? Select all that apply.
a. Vital signs
b. Urinary frequency
c. Increased suicidal ideation
d. Presence of abdominal pain and diarrhea
e. Hyperactivity or feelings of restlessness
ANS: A, D, E
The patient is taking the maximum dose of this SSRI and has ingested an additional unknown amount of the drug. Central serotonin syndrome must be considered. Symptoms include abdominal pain, diarrhea, tachycardia, elevated blood pressure, hyperpyrexia, increased motor activity, and muscle spasms. Central serotonin syndrome may progress to a full medical emergency if not treated early. Although assessing for suicidal ideation is never inappropriate, in this situation physiologic symptoms should be the initial focus. The patient may have urinary retention, but frequency would not be expected.

DIF: Cognitive Level: Analysis (Analyzing) REF: Page: 267 | Page: 270
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity