The nurse is interviewing a client admitted to an in-patient psychiatric unit with major depressive disorder. Which is the primary goal in the assessment phase of the nursing process for this client?

To build trust and rapport

To identify goals and outcomes

To collect and organize information

To identify and validate the medical diagnosis

Answer and Explanation

The Correct Answer is C

Nursing assessment is the foundational phase of the nursing process, focused on gathering comprehensive data about the client’s physical, emotional, cognitive, and behavioral status. In clients with major depressive disorder, this includes evaluating mood, affect, sleep patterns, appetite, energy levels, and suicidal ideation. The goal is to collect and organize subjective and objective information to guide accurate nursing diagnoses and individualized care planning.

Rationale for correct answer

3. The primary goal during assessment is to collect and organize relevant data. This includes health history, current symptoms, psychosocial context, and risk factors. Accurate data collection enables the nurse to formulate appropriate nursing diagnoses and interventions tailored to the client’s depressive presentation.

Rationale for incorrect answers

1. Building rapport is essential but not the primary goal of the assessment phase. It supports data collection and therapeutic engagement, but the phase itself is defined by systematic information gathering.

2. Identifying goals and outcomes occurs in the planning phase, after assessment and diagnosis. It involves setting measurable objectives based on the client’s needs and expected responses to interventions.

4. Validating the medical diagnosis is the role of the physician or psychiatrist. Nurses focus on nursing diagnoses, which are based on client responses to health conditions, not the confirmation of medical pathology.

Take Home Points

The assessment phase centers on collecting and organizing data to guide nursing care.
Building rapport supports assessment but is not its primary objective.
Goal setting and outcome identification occur in the planning phase.
Nurses do not validate medical diagnoses; they identify nursing responses to health conditions.

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Correct Answer is ["A","B","C"]

Explanation

Electroconvulsive therapy (ECT) is a controlled procedure used to treat severe depression, catatonia, and treatment-resistant psychiatric conditions. It involves inducing a brief generalized seizure under anesthesia. Pre-ECT medications are administered to reduce secretions, induce anesthesia, and prevent musculoskeletal injury. The goal is to optimize safety and minimize complications such as aspiration, prolonged seizures, or cardiovascular instability. Agents used must not interfere with seizure threshold or therapeutic efficacy.

Rationale for correct answers

1. Anticholinergic agents like glycopyrrolate reduce salivary and bronchial secretions, lowering aspiration risk and preventing bradycardia during ECT.

2. Anesthetic induction is achieved with thiopental, a short-acting barbiturate that provides rapid unconsciousness without significantly altering seizure threshold.

3. Muscle relaxation is critical to prevent injury during seizure. Succinylcholine, a depolarizing neuromuscular blocker, minimizes convulsive movements while preserving seizure activity.

Rationale for incorrect answers

4. Benzodiazepines like lorazepam raise seizure threshold and may blunt ECT efficacy. They are avoided unless treating status epilepticus or severe agitation.

5. Anticonvulsants such as divalproex suppress seizure activity and counteract ECT’s therapeutic mechanism. They are contraindicated unless treating comorbid epilepsy.

Take Home Points

Pre-ECT medications include anticholinergics, anesthetics, and muscle relaxants to ensure safety and efficacy.
Benzodiazepines and anticonvulsants interfere with seizure induction and are avoided before ECT.
Glycopyrrolate prevents bradycardia and aspiration by reducing secretions.
Succinylcholine minimizes physical injury during seizure without suppressing therapeutic activity.

A. Sit with the client and offer self frequently. B. Notify the client of group therapy schedule. C. Introduce the client to others on the unit. D. Help the client to identify stressors of life that precipitate life crises.

Correct Answer is A

Explanation

Major depressive disorder is a mood disorder marked by persistent sadness, anhedonia, and impaired functioning. Clients often exhibit psychomotor retardation, social withdrawal, and diminished verbal engagement, making initial therapeutic connection difficult. Early nursing goals prioritize presence, safety, and nonverbal rapport over verbal processing or group participation.

Rationale for correct answer

1. Establishing a therapeutic relationship with a client in acute depression requires nonverbal presence and emotional availability. Sitting quietly and offering self respects the client's limited energy and avoids pressure to engage. This intervention aligns with early-stage depression care, where trust-building precedes verbal interaction. It also addresses physiological needs by reducing isolation and promoting safety.

Rationale for incorrect answers

2. Group therapy requires motivation and cognitive engagement, which are often impaired in early stages of major depression. Introducing structured activities prematurely may overwhelm the client and hinder rapport.

3. Social introductions demand interpersonal energy and initiative, which are typically absent in clients with severe depression. Forcing socialization may increase anxiety and reinforce withdrawal.

4. Identifying stressors involves introspection, which is not feasible when the client is disengaged and nonverbal. This step is more appropriate after trust and communication have been established.

Take Home Points

Initial nursing interventions for major depressive disorder should prioritize presence and nonverbal support over verbal engagement.
Clients with psychomotor retardation and social withdrawal benefit from quiet companionship before structured therapy.
Group therapy and stressor identification are secondary interventions once rapport and communication are established.
Differentiating depression from conditions like schizophrenia or catatonia requires careful assessment of affect, engagement, and thought content.

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The nurse is interviewing a client admitted to an in-patient psychiatric unit with major depressive disorder. Which is the primary goal in the assessment phase of the nursing process for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following medications may be administered before electroconvulsive therapy? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A newly admitted client diagnosed with major depressive disorder isolates self in room and stares out the window. Which nursing intervention would be the most appropriate to implement initially, when establishing a nurse-client relationship?

Correct Answer is A

Explanation

Which symptom is an example of an affective alteration exhibited by clients diagnosed with severe depression?

A client diagnosed with major depressive disorder is being considered for electroconvulsive therapy (ECT). Which client teaching should the nurse prioritize?

Which is the key to understanding if a child or adolescent is experiencing an underlying depressive disorder?

A newly admitted depressed client isolates herself in her room and just sits and stares into space. How best might the nurse begin an initial therapeutic relationship with this client?

A client has just been admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which of the following behavioral manifestations might the nurse expect to assess? Select all that apply.

Which statement describes a major difference between a client diagnosed with major depressive disorder and a client diagnosed with dysthymic disorder?

A client diagnosed with major depressive disorder has an outcome that states, “The client will verbalize a measure of hope about the future by day 3.” Which client statement indicates this outcome was successful?

Which client is at highest risk for the diagnosis of major depressive disorder?