A nurse is caring for a client who was recently diagnosed with depression. The client's partner asks when he will get better. Which of the following is an appropriate response by the nurse?

Rationale:

• Dependent personality disorder: Characterized by excessive need to be taken care of and fear of separation. This does not fit the client’s symptoms of hopelessness, poor hygiene, flat affect, and suicidal thoughts, which are more consistent with major depression.
• Schizophrenia: Involves hallucinations, delusions, and disorganized behavior, none of which are reported in this client. The absence of psychosis and the presence of mood-based symptoms suggest a depressive disorder rather than a psychotic disorder.
• Major depressive disorder: Fits with the client's expression of hopelessness, withdrawal, poor hygiene, job loss, and suicidal ideation. These are classic symptoms of major depression and require careful monitoring and support.
• Dementia: Typically includes memory impairment, disorientation, and decline in cognitive function. The client is coherent, oriented, and presenting with mood rather than cognitive issues, ruling out dementia.
• Speak with the client using simple words: While clear communication is always beneficial, there is no indication the client has cognitive impairment requiring simplified language. The priority is emotional support and safety, not communication complexity.
• Remain in the room with the client: Ensures the client feels supported and safe, especially in the context of suicidal ideation. Continuous presence also allows for immediate intervention if the client's mental state worsens.
• Encourage client to eat slowly: Not relevant to the client’s presentation. There are no issues with appetite, swallowing, or physical illness necessitating this intervention. It does not address the mental health concerns at hand.
• Assist the client to identify stressors: Helps promote insight and develop coping mechanisms. Identifying stressors is essential in managing depressive symptoms and planning appropriate therapeutic strategies.
• Determine client’s level of disorientation: The client is not exhibiting signs of confusion or disorientation. This action would be more appropriate for cognitive disorders such as dementia or delirium.
• Panic attacks: The client reports anxiety but has not described acute panic symptoms like hyperventilation or chest tightness. Monitoring panic attacks is not a priority in this depressive context.
• Hallucinations: There is no evidence of perceptual disturbances. The client is not demonstrating psychosis, so monitoring for hallucinations is not indicated.
• Wandering at night: More relevant for clients with dementia or delirium. This client is coherent and not at risk of nocturnal wandering.
• Suicidal ideation: A key concern due to the client expressing that life is not worth living. This must be monitored continuously for client safety and to guide suicide prevention strategies.
• Sleep patterns: Depression commonly affects sleep, leading to insomnia or hypersomnia. Monitoring sleep helps gauge treatment response and overall progress in managing depressive symptoms.

Rationale:

• Document the blood product transfusion in the client’s medical record: It is essential to record the transfusion, including time started and ended, vital signs, and any reactions. Documentation ensures traceability, supports patient safety, and meets regulatory and institutional requirements.

• Monitor the client for the first 15 min of the transfusion: The first 15 minutes are the most critical for detecting transfusion reactions, such as fever, chills, rash, or anaphylaxis. Continuous monitoring during this window allows for prompt intervention if adverse symptoms occur.

• Assist with obtaining the first unit of packed RBCs from the blood bank: RNs or authorized personnel can retrieve blood from the blood bank. Proper handling and timely transport of the blood ensure viability and reduce the risk of hemolysis or temperature-related damage.

• Assist with titrating the rate of infusion to maintain the client’s blood pressure at 90/60 mm Hg or above: Titrating transfusion rates based solely on BP is not within nursing protocol unless specifically ordered. Blood products must be infused according to prescription typically over 2 to 4 hours per unit unless a reaction or complication occurs.

• Start an IV bolus of lactated Ringer’s solution: The provider specifically prescribed a 0.9% sodium chloride bolus. Lactated Ringer’s is contraindicated during transfusions because it contains calcium, which can cause clotting when mixed with blood products.

• Discard the blood bag in the client’s trash can after the transfusion: Blood bags must be disposed of in biohazard containers to comply with infection control policies. Discarding medical waste in general trash violates safety protocols and increases contamination risk.