Here are the answers for Depression Case Study HESI
The nurse completes a physical assessment. When asked what brought her to the hospital, Anna replies, "Things just aren't right" and begins to cry. After further conversation, Anna describes her mood as "very sad now." She rarely goes out or invites friends to visit. She admits that she feels like strangers are saying bad things about her. Sometimes she hears a man's voice that is a "little bit scary."
What question should the nurse ask as a priority nursing assessment?
"What is the voice saying to you?"
The daughter, an only child who is visiting from out of town, offers additional information about Anna's behaviors. The client's clothes fit looser and weight loss is evident. Current alcohol use is suspected, and a breathalyzer is positive for alcohol use. Anna denies current suicidal ideation, but the nurse recognizes that the client has risk factors for suicide based on the SAD PERSONS scale.
S = Sex. Men kill themselves more often than women, although women make more attempts.
A = Age. High-risk groups include 19-years-old or younger; 45-years-old or older, especially the elderly of 65-years or older.
D = Depression. Many of those who attempt suicide manifest a depressive syndrome.
P = Previous attempts. Of those who commit suicide, many have made previous attempts.
E = ETOH. Alcohol use is associated with up to 65% of suicides.
R = Rational thinking loss. People with psychoses are more likely to commit suicide than those in the general population.
S = Social supports lacking. A suicidal person often lacks significant others, meaningful employment, and other supports. These areas should be assessed.
O = Organized plan. The presence of a specific plan (date, place, means) signifies a person at high risk.
N = No spouse. Persons who are widowed, separated, divorced, or single are at greater risk than those who are married.
S = Sickness. Severe illness is a significant risk factor.
How many risk factors does Anna have?
Six points on the SAD PERSONS scale:
a. No spouse.
b. Lacks social support.
c. Loss of rational thinking suspected because she has thoughts of strangers talking about her and hearing a "scary voice."
d. Alcohol use.
e. Depressed mood.
f. Age older than 45-years.
What scale is used to score and interpret the SAD PERSON points?
0-2 points Treat at home with follow-up care.
3-4 points Closely follow up and consider possible hospitalization.
5-6 points Strongly consider hospitalization.
7-10 points Hospitalize.
Anna is assessed by the nurse, social worker, and healthcare provider. Based on their assessments, hospitalization is recommended for psychotic depression. Which behavior is inconsistent with depression?
Hearing a man's voice.
If the client refuses treatment, which behavior justifies short-term involuntary treatment?
Unable to meet basic self-care.
What classification of drugs is the antidepressant fluoxetine (Prozac)?
Selective serotonin reuptake inhibitor (SSRI).
What is the major action of SSRI antidepressants?
Increase availability of serotonin.
The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy. What is the rationale?
Tricyclics are more lethal in an overdose.
When the client receives fluoxetine (Prozac), the nurse must explain the purpose and when to expect therapeutic effectiveness. When should the client begin to feel less depressed?
1 to 3 weeks.
Which side effects commonly occur in clients who are taking SSRI antidepressants?
Gastrointestinal disturbances.
(GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or sedative side effects)
The nurse must explain the purpose of Risperdal. Which explanation is best?
"This medication will help you think more clearly."
(Antipsychotic medications target symptoms related to disorders of thinking such as psychosis and behaviors associated with agitation and disorganization or speech and behavior.)
The nurse understands that a VDRL is routinely done on admission for which reason?
It is a screening test for syphilis.
What role do thyroid levels play in depression?
Hypothyroidism can lead to feeling sluggish and depressed.
When Anna awakens in the morning, she sits for periods of time at the edge of her bed. She does not initiate combing her hair, getting dressed, or going to breakfast. Which nursing intervention is important?
Help the client with daily activities.
Since the client has decreased energy, which intervention is best?
Plan a scheduled rest period.
As the nurse initially communicates with Anna, which communication technique is important?
Reinforce that she will progressively feel better.
According to the nursing progress notes, Anna demonstrates decreased social interaction, rarely talks, needs assistance to her room, appears confused, and only slept 30 minutes in the past 24 hours. The daily graphics indicate that she has slept an average of 2 hours in the past week. She is eating 50% of her meals. According to this data, what is the priority nursing problem?
Sleep disturbance.
Since Anna is eating 50% of her meals, which priority nursing intervention should be included on the treatment plan?
Weigh weekly and document.
One morning the nurse takes Anna's morning blood pressure, which is 141/108. After reviewing the progress notes, there were several days when it was elevated. The nurse wants to validate if she has hypertension. Which DSM-IV-TR axis would the nurse use to interpret for the presence of hypertension?
Axis III (physiologic problems)
Which recommendation is best to minimize the risk of hypertension?
No added salt to diet.
The nurse knows that there are several risk factors for high blood pressure. Which risk factor does Anna have?
African-American.
(Other risk factors include a sedentary lifestyle and alcohol consumption.)
One morning the nurse is doing unit rounds and finds Anna sitting at the edge of her bed with a sheet around her neck. What is the first nursing action?
Stay with Anna.
When Anna wants to change clothes and get ready for sleep at night, what should the staff do?
Keep the door to Anna's room open.
(Keep the client's room door open so that the client will remain in eye sight at all times. Even if the client goes to the bathroom, the door should be kept open.)
Anna is placed on constant observation for safety precautions, so the nurse must assign a staff member to remain with her at all times. Which staff member is best to assign to Anna?
Unlicensed female counselor.
(The female counselor is an unlicensed staff member who can assume responsibility for the client's safety and maintain documentation. A female staff member is less threatening when the client desires as much privacy as possible.)
One afternoon the nurse notices that a visitor brings some cans of Anna's favorite soft drink. What should the nurse do?
Pour the soft drink into a paper cup. (Anna could use the can to hurt herself.)
After several days of constant observation, the nurse reassesses the need to maintain safety precautions. What will ensure that the client will be safe?
Anna agrees to talk with staff if thoughts of self-harm occur.
(If the client agrees to talk with staff if thoughts of self-harm occur, constant observation for safety can be changed. Risk for self-harm should continue to be assessed every shift.)
The nurse must teach the client about possible adverse effects from the ECT treatments. Which information should be included in the teaching plan?
Headache, nausea, and muscle aches may occur after the treatment. (Confusion and disorientation are short-term.)
When the nurse prepares a client for ECT, what should be expected?
Preparation is similar to a brief surgical procedure.
(NPO for 6 to 8 hours prior to treatment with the exception of receiving cardiac medications or antihypertensive agents. Prostheses should be removed, and the client should void immediately before receiving ECT.)
When Anna awakens from the treatment, the nurse should be prepared to perform which nursing action?
Take vital signs and assess orientation.
What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?
Headache and palpitations.
(Sudden elevation of blood pressure, chest pain, nausea, and vomiting are also some of the symptoms of a hypertensive crisis related to tyramine consumption.)
Unsafe foods have high tyramine content, and safe foods have little or no tyramine. Which food would be considered safe?
Most fruits.
(Except figs, especially if overripe, and bananas in large amounts.)
After several days of taking an MAO Inhibitor, Anna refuses to continue taking the medication and the medication is discontinued. Which specific nursing consideration is most important?
Maintain a low- or tyramine-free diet for 10 to 14 days.
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