Which of the following is an appropriate action by the nurse when a client diagnosed with depression suddenly seems cheerful and relaxed after 3 days of treatment?

Reward the client for their change in behavior.

Ask the client why their behavior has changed.

Encourage the family to take the client out of the facility for short periods of time.

Monitor the client's whereabouts at all times.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Rewarding the client for their change in behavior may seem positive, but it is not an appropriate nursing action in this context. It could reinforce the idea that only certain behaviors receive attention, which is not conducive to the therapeutic process.

Choice B reason:

Asking the client why their behavior has changed is not the most appropriate initial action. While understanding the client's perspective is important, it is more crucial to assess the situation for safety concerns, as sudden mood changes can sometimes precede impulsive actions.

Choice C reason:

Encouraging the family to take the client out of the facility for short periods of time is not advisable without a proper assessment of the client's stability and readiness for such activities. It is essential to ensure that the client is safe and that their treatment plan is being followed.

Choice D reason:

Monitoring the client's whereabouts at all times is the most appropriate action. A sudden change in mood can be a warning sign of increased risk for impulsive behavior, including self-harm or suicide. Continuous monitoring ensures the client's safety and allows for immediate intervention if necessary.

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Correct Answer is D

Explanation

Choice A Reason:

Meeting his daughter for dinner every week indicates that the client is maintaining social connections and engaging in regular activities. This behavior is generally considered healthy and adaptive, as it shows the client is seeking support and companionship, which are important aspects of coping with grief.

Choice B Reason:

Joining a bowling league 2 months ago suggests that the client is actively participating in social and recreational activities. This is a positive sign of adaptation and indicates that the client is finding ways to engage with others and enjoy life, which can be beneficial for mental health and well-being.

Choice C Reason:

Exercising at a local health facility 3 days each week demonstrates that the client is taking care of his physical health. Regular exercise is known to have numerous benefits, including reducing symptoms of depression and anxiety, improving mood, and enhancing overall well-being. This behavior is indicative of adaptive coping mechanisms.

Choice D Reason:

Keeping his partner's closet untouched since her death is a sign of maladaptive grief. This behavior suggests that the client is unable to move forward and is holding on to the past in a way that interferes with his ability to adapt to the loss. Maladaptive grief can manifest as an inability to accept the loss, persistent yearning for the deceased, and difficulty engaging in life without the deceased.

A. Scale for Assessment of Negative Symptoms (SANS) B. Abnormal Involuntary Movements Scale (AIMS) C. Mental Status Examination (MSE) D. Brief Patient Health Questionnaire (Brief PHQ)

Correct Answer is C

Explanation

Choice A reason:

The Scale for Assessment of Negative Symptoms (SANS) is primarily used for evaluating negative symptoms in schizophrenia and similar disorders, not cognitive disorders. Negative symptoms include affective flattening, alogia, avolition, anhedonia, and attentional impairment. While some of these symptoms may overlap with cognitive disorders, SANS is not specifically designed for cognitive assessment.

Choice B reason:

The Abnormal Involuntary Movements Scale (AIMS) is used to assess involuntary movements, which are often associated with the use of certain medications, such as antipsychotics. It is not a tool for assessing cognitive function but rather for monitoring potential medication side effects like tardive dyskinesia.

Choice C reason:

The Mental Status Examination (MSE) is a comprehensive assessment tool that evaluates a range of cognitive abilities including orientation, attention, memory, language, and executive functions. It is an appropriate inventory for assessing suspected cognitive disorders as it provides a structured way to evaluate cognitive impairment, which is crucial for diagnosing conditions like dementia.

Choice D reason:

The Brief Patient Health Questionnaire (Brief PHQ) is a screening tool for mental health disorders, particularly depression and anxiety. It is not specifically designed to assess cognitive disorders, although mood disorders can co-occur with cognitive impairment.

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Which of the following is an appropriate action by the nurse when a client diagnosed with depression suddenly seems cheerful and relaxed after 3 days of treatment?

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