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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
While the initial days after admission can be stressful and potentially risky for a patient with suicidal ideation, they are not typically considered the highest risk period.
Choice B rationale
Anniversaries of significant life events can indeed trigger emotional distress and potentially increase suicide risk. However, these are specific time points and not a continuous period of heightened risk.
Choice C rationale
The highest risk for self-harm in a patient with a history of suicidal ideation is often approximately 2 weeks after starting antidepressant medication. This is because as their mood begins to lift, they may still have suicidal thoughts but now have the energy to act on them.
Choice D rationale
While family visits can be emotionally charged and potentially distressing, they do not typically represent the highest risk period for self-harm.

A. Ineffective coping related to inadequate stress management. B. Hopelessness related to recent divorce. C. Spiritual distress related to conflicting thoughts about suicide and sin. D. Risk for suicide related to highly lethal plan.

Correct Answer is D

Explanation

Choice A rationale
While ineffective coping related to inadequate stress management is a valid nursing diagnosis, it is not the highest priority in this scenario. The client’s threat to commit suicide with a handgun indicates a clear and immediate risk.
Choice B rationale
Hopelessness related to recent divorce is a significant concern and may contribute to the client’s suicidal ideation. However, the immediate threat of suicide takes precedence.
Choice C rationale
Spiritual distress related to conflicting thoughts about suicide and sin may be a factor in the client’s mental state, but it is not the immediate concern. The client’s life is in danger, which must be addressed first.
Choice D rationale
Risk for suicide related to a highly lethal plan is the highest priority nursing diagnosis. The client has a clear plan (using a handgun) and means (access to a handgun), indicating a high risk for suicide.

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A patient has been admitted due to severe depression. What symptoms should the nurse anticipate during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with a history of suicidal ideation is under observation. When is the patient at the highest risk for self-harm?

Correct Answer is C

Explanation

A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority?

Correct Answer is D

Explanation

A confused older adult patient in a skilled nursing facility was asleep when unlicensed assistive personnel (UAP) entered the room quietly and touched the bed to see if it was wet. The patient awakened and hit the UAP in the face. Which statement best explains the patient’s action?

A recently widowed client is experiencing memory loss, insomnia, loss of appetite, and irritability over the last few months. Which data should the nurse obtain when assessing this client?

The practical nurse (PN) reviews the lab values. What Questions can the PN ask the client based on the lab results? Select all that apply.

A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

In a psychiatric unit, how are bright colors in the client’s environment often perceived?

A patient with cognitive impairment, who has been a widow for 30 years, is desperately trying to leave the facility, stating, “I have to go home to cook dinner before my husband gets home from work.”. How should the nurse intervene using validation therapy?

Upon entrance into a mental health care system, clients are thoroughly assessed, and this is followed by the development of a mental health treatment plan assessment. Which of the following are purposes of the treatment plan? (Select all that apply)

A client reports to the nurse that her elderly mother has become increasingly angry and responds inappropriately to conversations within the past few months. She notes that her mother does not respond when the mother’s back is turned. What is the best intervention for the nurse?