A nurse is assessing a patient with major depressive disorder (MDD). Which assessment tool can the nurse use to measure the severity and impact of depression on the patient’s functioning?

Choice A rationale:

Dry mouth is a common side effect of many medications, but it is not a distinctive side effect of SNRIs (Serotonin-Norepinephrine Reuptake Inhibitors). Dry mouth is more commonly associated with medications that affect salivary gland function, such as anticholinergic drugs.

Choice B rationale:

Weight loss can indeed be a side effect of SNRIs. These medications can impact appetite and metabolism, leading to weight loss in some individuals. However, it is not the most common or distinctive side effect when compared to other options.

Choice C rationale:

Constipation is a side effect that can occur with SNRIs, but it's not as prevalent or characteristic as some other side effects. Constipation is often associated with medications that have anticholinergic effects, which SNRIs generally have to a lesser extent.

Choice D rationale:

(Correct Choice) Insomnia is a well-known side effect of SNRIs. These medications can affect sleep patterns and may cause difficulties falling asleep or staying asleep. This side effect is particularly relevant to discuss with patients because it can impact their quality of life and overall well-being.

Choice A rationale:

Assessing the patient's medical history is crucial in understanding potential risk factors for suicide in patients with Major Depressive Disorder (MDD). Various medical conditions and medications can contribute to depression and increase the risk of suicidal ideation. By gathering this information, the nurse can identify any factors that might exacerbate the patient's condition.

Choice B rationale:

Monitoring the patient's response to treatment is essential for assessing the effectiveness of interventions and identifying any signs of worsening depression or increased suicidal risk. Certain treatments, like antidepressant medications, might initially increase the risk of suicide in some patients. Therefore, close monitoring is needed to ensure patient safety.

Choice C rationale:

Asking direct questions about suicidal thoughts is a critical component of assessing suicide risk in patients with MDD. Openly addressing this topic allows the nurse to gauge the patient's current state of mind, explore the presence and severity of suicidal ideation, and take appropriate actions if the patient expresses active suicidal thoughts.

Choice D rationale:

Providing a list of local crisis helplines can be beneficial, but it is not a component of the nursing assessment for suicide risk in patients with MDD. While offering resources is important, the immediate focus should be on assessing the patient's condition and potential risk factors.

Choice E rationale:

Encouraging the patient to isolate themselves is not an appropriate action when assessing suicide risk in patients with MDD. Social isolation can exacerbate depressive symptoms and increase the risk of suicide. Therefore, promoting social connection and support is essential, rather than encouraging isolation.