A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?
The client’s behavioral change is expected after the time period of medication.
The client may have worked out details of their suicide plan.
The medication dosage should be decreased and a mood stabilizer added.
The medication has potentiated serotonin syndrome.
The Correct Answer is A
The correct answer is a. The client’s behavioral change is expected after the time period of medication.
Choice A Reason:
This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.
Choice B Reason:
This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.
Choice C Reason:
This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.
Choice D Reason:
This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Several visits of the same child with varied injuries.
Explanation of Choices
Choice A Reason: Several Visits of the Same Child with Varied Injuries
This scenario raises the highest suspicion of child abuse. Multiple visits with different injuries can indicate a pattern of harm rather than isolated accidents. Healthcare providers are trained to recognize that varied injuries over time, especially in different stages of healing, can be a red flag for abuse. This pattern suggests that the child may be experiencing ongoing harm rather than a single incident. The nurse should conduct a thorough assessment and consider involving child protective services to ensure the child’s safety.
Choice B Reason: A 5-Year-Old Child Who Broke His Arm and Clings to Mother Crying
While a broken arm in a child can be concerning, it is not uncommon for children to sustain such injuries during play or accidents. The child’s emotional response of clinging to the mother and crying is also typical for a young child in pain and distress. This scenario alone does not strongly indicate abuse without additional context or evidence. However, the nurse should still assess the situation carefully and consider any other signs or patterns that might suggest abuse.
Choice C Reason: A 1-Year-Old Child Who Has a Dislocated Shoulder from Arm Swinging
A dislocated shoulder in a 1-year-old is unusual and can be concerning. While it could result from an accident, such as arm swinging, it is also a potential sign of abuse, especially if the explanation does not match the injury. The nurse should investigate further, considering the child’s medical history and any other signs of potential abuse. However, this scenario alone does not provide as strong an indication of abuse as multiple varied injuries.
Choice D Reason: Repeated Visits of the Same Child with Middle Ear Infections
Repeated visits for middle ear infections are common in young children and are typically related to medical issues rather than abuse. Middle ear infections can occur frequently in children due to their anatomy and immune system development. This scenario does not raise immediate concerns about abuse unless there are other signs or patterns of harm. The nurse should focus on providing appropriate medical care and monitoring the child’s health.
Correct Answer is ["A","B","C"]
Explanation
Choice A Reason: “I’d rather be dead than live like this. I do not want to be alive.”
This statement reflects suicidal ideation, which is a common symptom of major depressive disorder (MDD). Individuals with MDD often experience feelings of hopelessness and worthlessness, leading them to believe that life is not worth living. Suicidal thoughts are a serious concern and require immediate attention and intervention.
Choice B Reason: “If I can just keep ignoring my feelings, I’ll be fine.”
This statement indicates a form of denial or avoidance, which is also common in individuals with MDD. People with depression may try to ignore or suppress their feelings in an attempt to cope with their condition. However, this approach is generally ineffective and can lead to worsening symptoms over time.
Choice C Reason: “I deserve to be this way. I’ve not accomplished anything important in my life.”
Feelings of worthlessness and excessive guilt are hallmark symptoms of MDD. Individuals with depression often have a negative self-view and believe that they are failures or that they deserve to suffer. This distorted thinking pattern can significantly impact their overall well-being and quality of life.
Choice D Reason: “This is a bad episode, but I will be well soon.”
This statement reflects a more optimistic outlook, which is less common in individuals with MDD. While some people with depression may have moments of hope, the pervasive nature of the disorder typically leads to a more negative and hopeless perspective. Therefore, this choice is less likely to be heard during an intake assessment for MDD.
Choice E Reason: “I am determined to fight this episode and get through it.”
Similar to choice D, this statement indicates a positive and proactive attitude towards managing depression. While determination and resilience are important for recovery, they are not typically expressed by individuals during the acute phase of MDD. This choice is also less likely to be heard during an intake assessment for MDD.
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