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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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.

Choice B rationale:

The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.

Choice C rationale:

Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.

Choice D rationale:

Administering ferrous sulfate is unrelated to the client's symptoms and concerns.

A. Ensure padded wrist restraints are in the client's room. B. Initiate IV access for the client. C. Administer lorazepam every 4 hr to sedate the client. D. Place an incontinence brief on the client

Correct Answer is B

Explanation

Choice A rationale:

Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.

Choice B rationale:

After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.

Choice C rationale:

Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.

Choice D rationale:

Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.

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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?

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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?