A nurse is assessing a client who has a new diagnosis of major depressive disorder.
Which of the following client statements should the nurse expect?
"I feel like my mood has been all over the place."
"I recently started hearing voices in my head."
“I cannot trust you enough to tell you how I feel."
"just don't feel like doing things I usually enjoy."
"just don't feel like doing things I usually enjoy."
The Correct Answer is D
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Correct Answer is C
Explanation
Choice A rationale:
Awakening the client frequently throughout the day is not necessary and can disturb their rest and comfort.
Choice B rationale:
Using an electric blanket can increase the risk of burns or overheating in a client who is approaching death and may have reduced ability to regulate body temperature.
Choice C rationale:
Positioning the client on their side with the head of the bed elevated can facilitate drainage of respiratory secretions, maintain airway patency, and provide comfort.
Choice D rationale:
Encouraging the client to eat soft foods intermittently may not be relevant, as the client's ability to eat and swallow may be limited in the end stages of life.
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