which of the following interventions should a nurse include in the care plan for a client with major depressive disorder select one that doesnt apply
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ATI RN

ATI Mental Health Proctored Exam 2023 Quizlet

1. Which of the following interventions should a nurse include in the care plan for a client with major depressive disorder? Select one that is not appropriate.

Correct answer: C

Rationale: Interventions for a client with major depressive disorder should focus on encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discouraging verbalization of feelings goes against the therapeutic approach as expressing and discussing feelings is crucial in the treatment of major depressive disorder. Clients with major depressive disorder often benefit from talking about their emotions and experiences, as it can help in processing their feelings and promoting recovery. Therefore, discouraging verbalization of feelings would hinder the client's progress and is not an appropriate intervention.

2. A patient with major depressive disorder is started on a tricyclic antidepressant (TCA). Which common side effect should the nurse educate the patient about?

Correct answer: C

Rationale: The correct answer is C: Dry mouth. Dry mouth is a common side effect associated with tricyclic antidepressants (TCAs). TCAs block acetylcholine receptors, leading to anticholinergic effects such as dry mouth, constipation, blurred vision, and urinary retention. It is important for the nurse to educate the patient about this side effect to promote awareness and provide appropriate management strategies, such as maintaining good oral hygiene and staying hydrated. Choice A, hypertension, is not a common side effect of TCAs. Choice B, diarrhea, is not a typical side effect of TCAs; in fact, TCAs are more likely to cause constipation. Choice D, weight loss, is less common with TCAs as they are more likely to cause weight gain.

3. A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?

Correct answer: D

Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.

4. A healthcare professional is assessing a client diagnosed with body dysmorphic disorder. Which of the following findings should the healthcare professional expect?

Correct answer: A

Rationale: The correct answer is A: Preoccupation with a perceived physical defect. Individuals with body dysmorphic disorder exhibit an obsessive preoccupation with a perceived flaw in their physical appearance, which is often minor or not noticeable to others. This preoccupation causes distress and leads to repetitive behaviors like mirror checking or seeking reassurance about their appearance. Choices B, C, and D are incorrect because fear of gaining weight is more characteristic of an eating disorder, excessive worry about physical symptoms may be seen in somatic symptom disorder, and persistent depressive mood aligns more with depressive disorders rather than body dysmorphic disorder.

5. A healthcare professional is assessing a client diagnosed with paranoid schizophrenia. Which of the following findings should the healthcare professional expect?

Correct answer: B

Rationale: The correct answer is B: Delusions of grandeur. Clients with paranoid schizophrenia often experience delusions of grandeur or persecution, auditory hallucinations, and a flat affect. However, the most characteristic finding for paranoid schizophrenia is the presence of delusions, which are fixed false beliefs that are not based in reality. Delusions of grandeur, where individuals believe they are exceptionally powerful or important, are commonly seen in paranoid schizophrenia. Choice A, auditory hallucinations, are more commonly associated with other types of schizophrenia such as paranoid or disorganized schizophrenia. Choice C, a flat affect, is a symptom that can be seen across various types of schizophrenia. Choice D, disorganized speech, is more indicative of disorganized schizophrenia.

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