A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

"I know that I will be reunited with my child someday."

"I am unable to feel any joy since my child died."

"I feel guilty because my child died."

"I am angry that my child died."

Answer and Explanation

The Correct Answer is B

A. Belief in being reunited with the child is a common and healthy coping mechanism.

B. Inability to experience joy (anhedonia) is a key symptom of major depressive disorder and warrants further assessment.

C. Feeling guilty is a normal part of grief but does not necessarily indicate major depression.

D. Anger is a normal stage of grief and does not typically indicate a disorder unless prolonged or extreme.

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Correct Answer is D

Explanation

A. Monitor vital signs every hour for the first 4 hr: Incorrect. Vital signs should be monitored more frequently, typically every 15 minutes during the first hour after administration, due to the risk of bleeding.

B. Administer medications intramuscularly: Incorrect. Intramuscular injections should be avoided while the client is on alteplase due to the increased risk of bleeding.

C. Provide a diet low in protein: Incorrect. There is no need for a low-protein diet with alteplase therapy. The focus should be on managing bleeding risks and monitoring for complications.

D. Observe for bruising of the skin: Alteplase is a thrombolytic medication, and one of its major side effects is bleeding. The nurse should monitor the client for signs of bruising, bleeding, or hemorrhage.

A. "I had to retire because my boss didn't like me." B. "There were lay-offs at my company, so I journaled about what I accomplished during my career." C. "I'm so glad I've retired because the work was making me sick and depressed." D. "Since I retired, I have entered many gardening competitions."

Correct Answer is D

Explanation

A. "I had to retire because my boss didn't like me.": Indicates projection, attributing personal feelings to someone else.

B. "There were lay-offs at my company, so I journaled about what I accomplished during my career.": Indicates positive coping, not compensation.

C. "I'm so glad I've retired because the work was making me sick and depressed.": Indicates rationalization, justifying the situation.

D. "Since I retired, I have entered many gardening competitions.": The client is compensating for the loss of work-related identity by engaging in competitive gardening, a constructive coping strategy.

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A nurse is assessing the grief response of a client whose child died 6 months ago. Which of the following client statements should the nurse report to the provider as an indication of major depressive disorder?

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Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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