HESI Case Studies–Psychiatric/Mental Health-Major Depressive Disorder (Joan Miller)

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1. During the initial assessment, the nurse should focus on which areas? (Select all)
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-Symptoms of anxiety -Increasing symptoms of depression -Suicidal ideation
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2. What should the nurse say to elicit the most subjective information from the client?
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“Tell me more about your anxiety.”
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3. The nurse recognizes that Joan is experiencing what level of anxiety?
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Severe
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4. Which question is most important for the nurse to ask Joan?
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Do you have a plan for harming yourself?
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5. How should the nurse respond to Joan’s comments?
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“Tell me more about your chest pain.”
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6. Which nursing diagnosis for the client’s anxiety should the nurse record?
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Ineffective coping related to interpersonal conflicts
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7. Which behavior should the nurse illicit from the client?
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Stating the sources for present anxiety
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8. Which nursing diagnosis should the nurse add to Joan’s plan of care? (Select all)
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-Anxiety related to maturational crisis -Powerlessness related to work conflict -Situational low self-esteem related to work
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9. Which question or statement by the nurse is most likely to encourage Joan to talk about the issues that are contributing to her anxiety?
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“What does being 52 years old mean to you?”
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10. How should the nurse answer Joan’s question about when to take the lorazepam (Ativan)?
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“Measure your anxiety on a scale, then decide when to use lorazepam (Ativan), but do not exceed twice a day.”
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11. What information should the nurse discuss with Joan about bupropion (Wellbutrin XL)?
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Anxiety level may increase
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12. Before Joan has the prescription for bupropion (Wellbutrin XL) filled, the nurse should ensure that the client has not experienced whihc problem(s)? (Select all)
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-Anorexia or bulimia -Seizures
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13. How should the nurse respond to Joan’s question?
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Do not consume alcohol while taking the medication
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14. lorazepam (Ativan) is ordered as 0.5mg. The pharmacy only has 1mg tabs available. How many tabs should the nurse instruct Joan to take with each dose?
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0.5
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15. How should the nurse respond to Joan’s complain of headaches?
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“The headaches usually go away within a few days.”
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16. What is the most important question the nurse should ask the client once the client is taking the medication bupropion (Wellbutrin XL)?
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“Have you had any suicide thoughts since starting bupropioon (Wellbutrin XL)?”
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17. Which question should the nurse ask Joan first?
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How do you plan to hurt yourself?
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18. How should the nurse respond to Joan?
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“Go to the hospital now because this is a serious situation.”
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19. Which statement by the client best suggests that the medication combination and therapy are working?
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“The things that happen at work don’t bother me so much.”
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20. How should the nurse respond to the client’s statement?
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“Most clients do better by taking the medicine for a year.”
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21. On which statement by the client is the nurse basing this assessment?
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“I just tell the boss that nothing she does will upset me.”
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22. The nurse knows that Joan is still easily upset by her boss’ behavior. How should the nurse respond to Joan?
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“How do you feel when your boss says something that upsets you?”
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23. In considering Joan’s statements about her interactions with her boss, which standard of the ANA Psychiatric-Mental Health Nursing care should the nurse apply to the current situation?
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Assessment
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24. What makes termination important to the nurse-client relationship?
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Termination summarizes the goals and objectives attained
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25. How should the nurse respond to Joan’s request?
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Instruct the client to make an appointment for follow-up

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