A patient has been admitted due to severe depression. What symptoms should the nurse anticipate during the assessment?
Changes in sleep pattern, fatigue, and an elevated mood.
Depressed mood, feelings of guilt, and rapid speech.
Difficulty concentrating, feelings of helplessness, and rapid shifts in thoughts.
Feelings of hopelessness, worthlessness, and difficulty focusing.
The Correct Answer is D
Choice D rationale
Feelings of hopelessness, worthlessness, and difficulty focusing are common symptoms of severe depression. Depression is a serious mood disorder that affects how a person feels, thinks, and handles daily activities. To be diagnosed with depression, the symptoms must be present for at least 2 weeks.
Choice A rationale
Changes in sleep pattern and fatigue are symptoms of depression, but an elevated mood is not. An elevated mood is more commonly associated with bipolar disorder.
Choice B rationale
While a depressed mood and feelings of guilt are symptoms of depression, rapid speech is not. Rapid speech is more commonly associated with mania or hypomania, conditions seen in bipolar disorder.
Choice C rationale
Difficulty concentrating and feelings of helplessness are symptoms of depression, but rapid shifts in thoughts are not. Rapid shifts in thoughts are more commonly associated with conditions such as bipolar disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Ideas of reference involve the belief that casual events, people’s remarks, or elements in the environment have a particular and unusual meaning specifically for oneself. This is not what is being described in the question.
Choice B rationale
Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. It is usually caused by a brain injury or other organic disorder. This is not what is being described in the question.
Choice C rationale
Flight of ideas is a symptom of a thought disorder that causes a rapid shift from one idea to another. This symptom is often seen in conditions like bipolar disorder, particularly during manic episodes. This matches the description given in the question.
Choice D rationale
Confabulation is a memory disturbance in which a person confuses imagined scenarios with actual memories, with no intent to deceive. This is not what is being described in the question.
Correct Answer is D
Explanation
Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.
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