A client with depression is prescribed an SSRI. The client asks, 'Why do I need to take this medication every day?' What is the best response by the nurse?

Correct Answer: D

Rationale: The correct response is option D) "You should take this medication only when you feel sad or depressed." This option is incorrect because it goes against best practices in mental health nursing. The best response should be option B) "This medication needs to be taken regularly to be effective." This answer is correct because SSRIs, like most antidepressants, require consistent daily intake to reach and maintain therapeutic levels in the body. Missing doses or taking the medication inconsistently can lead to reduced effectiveness and may even exacerbate symptoms. Option A) "This medication will help balance the chemicals in your brain" is partially correct in explaining the mechanism of action of SSRIs, but it fails to emphasize the importance of daily compliance. Option C) "This medication will start working immediately to improve your mood" is incorrect as SSRIs typically take several weeks to build up in the system and produce noticeable effects. In an educational context, it is crucial for nurses to effectively communicate the rationale behind medication regimens to clients to ensure adherence and optimal treatment outcomes. Understanding the importance of regular medication intake is fundamental in managing mental health conditions like depression, and nurses play a key role in promoting medication adherence and providing accurate information to empower clients in their treatment journey.

Correct Answer: D

Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.

Correct Answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

Correct Answer: B

Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.