HESI Case Studies–Psychiatric/Mental Health-Depression (Anna Gray) Essay

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1. What question should the nurse ask as a priority nursing assessment?
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“What is the voice saying to you?”
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2. How many points does Anna have?
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6
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3. Which behavior is inconsistent with depression?
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Hearing a man’s voice
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4. If the client refuses treatment, which behavior(s) justify short-term involuntary treatment? (Select all)
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-Unable to meet basic self-care needs -States she has a plan to harm herself
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5. In what classification of drugs is the antidepressant fluoxetine (Prozac)?
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Selective serotonin reuptake inhibitor (SSRI)
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6. What is the major action of SSRI antidepressants?
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Increase availability of serotonin
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7. The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy. What is the rationale?
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Tricyclics are more lethal in an overdose
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8. When should the client begin to feel less depressed?
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1 to 3 weeks
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9. Which side effects commonly occur in clients who are taking SSRI antidepressants?
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Gastrointestinal disturbances
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10. Which explanation is best?
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“This medication will help you think more clearly.”
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11. The nurse understands that a VDRL is routinely done on admission for which reason?
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It is a screening test for syphilis
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12. What role do thyroid levels play in depression?
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Hypothyroidism can lead to feeling sluggish and depressed
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13. Which intervention is important?
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Help the client with daily activities
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14. Since the client has decreased energy, which intervention is best?
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Plan a scheduled rest period
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15. As the nurse initially communicates with Anna, which communication technique is important?
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Reinforce that she will progressively feel better
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16. According to this data, what is the priority nursing problem?
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Sleep disturbance
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17. Since Anna is eating 50% of her meals, which priority nursing intervention should be included on the treatment plan?
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Weigh weekly and document
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18. Which DSM-V axis would the nurse use to interpret for the presence of hypertension?
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Axis III
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19. Which recommendation is best to minimize the risk of hypertension?
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No added salt in diet
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20. Which risk factor does Anna have?
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African-American
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21. One morning the nurse is ding unit rounds and finds Anna sitting at the edge of her bed with a sheet around her neck. What is the first nursing action?
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Stay with Anna
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22. When Anna wants to change clothes and get ready for sleep at night, what should the staff do?
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Keep the door to Anna’s room open
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23. Which staff member is best to assign to Anna?
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Unlicensed female counselor
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24. What should the nurse do?
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Pour the soft drink into a paper cup
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25. What is the best predictor of safety?
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Anna agrees to talk with staff if thoughts of self-harm occur
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26. Which information should be included in the teaching plan?
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Headache, nausea, and muscle aches may occur after the treatment
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27. When the nurse prepares a client for ECT, what should be expected?
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Preparation is similar to brief surgical procedure
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28. When Anna awakens from the treatment, the nurse should be prepared to perform which nursing action?
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Take vital signs and assess orientation
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29. What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?
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Headache and palpitations
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30. Which food would be considered safe?
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Most fruits
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31. Which specific nursing consideration is most important?
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Maintain a low-tyramine or tyramine-free diet for 10 to 14 days

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