HESI Major Depressive Disorder, Feeding and Eating
Disorder Questions With Complete Solutions
After 4 weeks of therapy, the client calls the clinic's emergency
line, crying and reports that there is nothing to live for. Which is
the most important information the nurse should obtain from the
client?
-If the client has a plan and means to harm self.
-The client's desire to carry out a suicide plan.
-Ask the client if there is anyone there with them.
-Discuss with the client ways to make sure not to cause self
harm. Correct Answer -If the client has a plan and means to
harm self.
When assessing for suicidal ideation, the nurse must first
determine if the client has a means to harm themselves, then the
true desire to do self-harm. The second phase of suicide
prevention involves making a no-self harm plan. Lastly, the
presence/absence of a support system is useful information.
Assessment The triage nurse performs a more in-depth
assessment of the client's complaints and reports the assessment
to the Advanced Practice Registered Nurse in Psychiatric-
Mental Health (APRN-PMH). These two nurses collaborate on
development of the care plan to facilitate assessment and
interventions for the client's anxiety. During the initial
assessment, the nurse should focus on which areas that are most
characteristic of anxiety? (Select all that apply. One, some, or all
responses may be correct.)
-Symptoms restlessness, difficulty concentrating, and irritability.
-Social interactions such as withdrawal, shunning family and
drinking alcohol.
,-Increasing symptoms of depression with consistently sad, low
mood.
-Behavioral alterations including hallucinations.
-Suicidal ideation. Correct Answer -Symptoms restlessness,
difficulty concentrating, irritability.
Hildegard Peplau identified four levels of anxiety defined by
physical symptoms. Identification of the specific level of anxiety
is essential because interventions are based on the degree of the
client's anxiety .term-1
-Increasing symptoms of depression with consistently sad, low
mood.
There is a high comorbid rate of anxiety and depression. Often
clients who are diagnosed with both of these diseases are at
increased risk for suicidal ideation.
-Suicidal ideation.
There is a high comorbid rate of anxiety and depression. Often
clients who are diagnosed with anxiety and depression are at
increased risk for suicidal ideation.
Before the client has the prescription for bupropion filled, the
nurse should ensure that the client has not experienced which
problem(s)? (Select all that apply. One, some, or all responses
may be correct.)
-Tachycardia.
-Anorexia or bulimia.
-Peptic ulcer disease.
-Hypertension.
-Seizures. Correct Answer -Anorexia or bulimia.
Anorexia and bulimia are both contraindications for bupropion
because of a higher incidence of seizures experienced by clients
treated for bulimia.
, -Seizures.
Clients with a history of seizures are at higher risk for seizures
when taking bupropion.
During the conversation with the nurse on the clinic's emergency
line, the client tells the nurse about thoughts of taking an
overdose. The client tells the nurse about having prescriptions
for lorazepam and bupropion. The nurse knows that an overdose
of this combination of drugs could be lethal. How should the
nurse respond to the client?
-Inform the client of concern regarding safety and call the
police.
-Contact the client's family to tell them what the client is saying.
-Tell the client to get rid all that medication by flushing it down
the toilet.
-Express concern and determine if someone can take the client
to the hospital. Correct Answer -Express concern and
determine if someone can take the client to the hospital.
At this point, the client should be assessed for possible hospital
admission. Determining if someone is available to transport the
client reduces the likelihood that the client will drive while
feeling suicidal.
During the initial 8 hours of one-on-one nurse staffing, the client
is able to verbally contract with the primary nurse to disclose
any thoughts of self-harm. What is the nurse's primary purpose
for establishing a treatment contract with the client?
-To focus on the client's anxiety in relation to oral nutrition.
-To allow the client to decide whether or not thoughts of self-
harm will be disclosed.
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