A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?

The client’s behavioral change is expected after the time period of medication.

The client may have worked out details of their suicide plan.

The medication dosage should be decreased and a mood stabilizer added.

The medication has potentiated serotonin syndrome.

Answer and Explanation

The Correct Answer is A

The correct answer is a. The client’s behavioral change is expected after the time period of medication.

Choice A Reason:

This choice is correct because fluoxetine, a selective serotonin reuptake inhibitor (SSRI), typically takes about 4 to 6 weeks to start showing its full effects. The client’s statement, “I feel like a great weight is off my chest,” indicates a positive response to the medication, which aligns with the expected timeline for SSRIs to improve mood and alleviate symptoms of depression. This behavioral change suggests that the medication is working as intended, helping to lift the depressive symptoms.

Choice B Reason:

This choice is incorrect and concerning. While it is true that some individuals may experience a temporary increase in energy before their mood improves, which could potentially increase the risk of suicide, the client’s positive statement does not necessarily indicate suicidal planning. It is important for healthcare providers to continuously monitor for any signs of suicidal ideation, but in this context, the client’s statement more likely reflects an improvement in their depressive symptoms.

Choice C Reason:

This choice is incorrect because there is no indication that the medication dosage should be decreased or that a mood stabilizer should be added. Fluoxetine is generally well-tolerated, and the client’s positive response suggests that the current dosage is effective. Mood stabilizers are typically used in the treatment of bipolar disorder, not major depressive disorder, unless there is a specific indication for their use.

Choice D Reason:

This choice is incorrect and indicates a misunderstanding of serotonin syndrome. Serotonin syndrome is a potentially life-threatening condition caused by excessive serotonin activity in the brain, often due to drug interactions or overdose. Symptoms include agitation, confusion, rapid heart rate, and high blood pressure4. The client’s statement of feeling relieved does not align with the symptoms of serotonin syndrome, which are generally severe and require immediate medical attention.

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Correct Answer is D

Explanation

Choice A Reason: Is not responding to other clients on the unit.

While a lack of response to other clients can indicate social withdrawal and isolation, which are common in depressive episodes, it does not necessarily indicate an immediate risk to the client’s safety. This behavior is concerning but does not require the highest priority intervention compared to other behaviors that may indicate a risk of self-harm or suicidal ideation.

Choice B Reason: Is refusing to take their prescribed mood stabilizer.

Refusing medication is a significant concern as it can lead to worsening of symptoms and destabilization of the client’s condition. However, this behavior does not indicate an immediate risk to the client’s safety. The nurse should address this issue promptly, but it is not the highest priority compared to behaviors that suggest suicidal ideation.

Choice C Reason: Angrily argues with another client stating, “God is dead.”

This behavior indicates agitation and potential conflict with others, which can be problematic in a clinical setting. However, it does not directly suggest an immediate risk to the client’s safety. The nurse should intervene to de-escalate the situation and provide support, but this is not the highest priority compared to signs of suicidal ideation.

Choice D Reason: States, “There is no future when you feel so depressed.”

This statement is highly concerning as it indicates feelings of hopelessness and potential suicidal ideation. Expressions of hopelessness and statements about the future being bleak are significant risk factors for suicide. The nurse should prioritize this behavior for immediate intervention to assess the client’s risk of self-harm and provide appropriate support and safety measures.

A. The diathesis-stress model assists the client in identifying their level of stress or anxiety. B. The diathesis-stress model assists in telling me how stressed a client is. C. The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress. D. The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

Correct Answer is C

Explanation

Choice A Reason: The diathesis-stress model assists the client in identifying their level of stress or anxiety.

This statement is incorrect because the diathesis-stress model does not primarily focus on helping clients identify their current levels of stress or anxiety. Instead, it is a framework used to understand how predispositional vulnerabilities (diatheses) and external stressors interact to influence the development of psychological disorders. While understanding stress levels can be part of a broader assessment, it is not the main purpose of the diathesis-stress model.

Choice B Reason: The diathesis-stress model assists in telling me how stressed a client is.

This statement is also incorrect. The diathesis-stress model is not a tool for measuring or quantifying a client’s current stress levels. Rather, it is a theoretical model that explains how stress interacts with an individual’s vulnerabilities to potentially trigger mental health issues. The model helps clinicians understand the interplay between genetic, biological, and environmental factors, but it does not provide a direct measure of stress.

Choice C Reason: The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress.

This statement is correct. The diathesis-stress model is designed to identify and understand the risk factors or vulnerabilities (diatheses) that make an individual more susceptible to developing psychological disorders when exposed to stress. These vulnerabilities can be genetic, biological, psychological, or situational. By identifying these factors, clinicians can better predict which individuals are at higher risk for developing mental health issues under stress and can tailor interventions accordingly.

Choice D Reason: The diathesis-stress model assists in identifying what mental health disorder related to stress the client has.

This statement is partially correct but not entirely accurate. While the diathesis-stress model can help in understanding the development of mental health disorders, it does not specifically identify which disorder a client has. The model provides a framework for understanding how various factors contribute to the onset of disorders, but a comprehensive clinical assessment is required to diagnose specific mental health conditions.

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A client with major depressive disorder has been taking fluoxetine, an SSRI, for 5 weeks. During the first outpatient visit, the client smiles and states, “I feel like a great weight is off my chest.” How should the nurse interpret this behavior change?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the model?

Correct Answer is C

Explanation

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