A nurse at a primary care clinic is collecting data on a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?
"Lately, I feel like I am more alert than usual and can focus better."
"I can't sit still. I feel like I need to be doing things around the house."
"When I went to my provider, they told me I have high blood pressure."
"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours."
The Correct Answer is D
A. "Lately, I feel like I am more alert than usual and can focus better.": Depression is commonly associated with difficulties in concentration, memory impairment, and slowed cognitive function rather than increased alertness or improved focus. Clients with depression often report feeling mentally sluggish or experiencing brain fog.
B. "I can't sit still. I feel like I need to be doing things around the house.": While some individuals with depression experience psychomotor agitation, it is more common for depression to present with fatigue, low energy, and decreased motivation. Restlessness may also be seen in anxiety disorders, but it is not a primary symptom of depression.
C. "When I went to my provider, they told me I have high blood pressure.": Hypertension is a medical condition that may have various causes, but it is not a direct manifestation of depression. However, chronic stress and depression can contribute to cardiovascular issues over time, though depression itself is primarily characterized by emotional and cognitive symptoms.
D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.": Insomnia and difficulty falling or staying asleep are hallmark symptoms of depression. Clients often experience ruminative thoughts, early-morning awakenings, or non-restorative sleep, which can contribute to worsened mood, fatigue, and impaired daily functioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Notify child protective services." Reporting to child protective services is only necessary if there is evidence of abuse, neglect, or an inability to provide adequate care. A diagnosis of borderline personality disorder alone does not warrant an automatic report.
B. "Suggest the children live with other relatives." Encouraging a client to relinquish custody without evidence of an inability to care for the children is not appropriate. Providing support and resources to enhance parenting skills is a more beneficial approach.
C. "Encourage the children to visit the psychiatric unit when the client is leaving." While family involvement is important, exposing young children to a psychiatric unit can be overwhelming and inappropriate. Alternative ways to support parent-child bonding should be considered.
D. "Offer the client information about a support group for parents." Support groups provide a structured environment for clients to share experiences, receive guidance, and develop coping strategies, which can help manage stress and improve parenting skills.
Correct Answer is C
Explanation
A. Stimulants. Stimulant intoxication typically causes increased energy, agitation, tachycardia, and paranoia, but it does not usually induce hallucinations to the extent described. While severe stimulant use (e.g., methamphetamine or cocaine) can cause paranoia, the significant perceptual disturbances and visual hallucinations suggest a different category of drugs.
B. Opioids. Opioid intoxication generally leads to central nervous system depression, respiratory depression, pinpoint pupils, and sedation rather than paranoia, hallucinations, and erratic behavior. The described symptoms do not align with opioid use.
C. Hallucinogens. Hallucinogen use, such as LSD or PCP, can cause altered perception, paranoia, visual hallucinations, and erratic behavior. The client’s symptoms—paranoia, visual disturbances, mumbling, and gesturing—are characteristic of hallucinogen intoxication, making this the most likely cause.
D. Anabolic steroids. Anabolic steroid use can lead to mood swings, aggression, and psychotic symptoms in some cases, but it does not typically cause acute hallucinations, paranoia, or perceptual disturbances. The symptoms described do not fit anabolic steroid use.
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