A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?

Correct Answer: D

Rationale: In this scenario, option D, "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours," is consistent with manifestations of depression. This statement reflects symptoms such as racing thoughts and insomnia, which are common in individuals experiencing depression. Option A is incorrect as it describes a physical health condition (high blood pressure) rather than emotional or mental health concerns associated with depression. Option B indicates increased alertness and improved focus, which are not typical symptoms of depression but could suggest other conditions like anxiety. Option C describes restlessness and a need for constant activity, which is more indicative of conditions like anxiety or hyperactivity rather than depression. Educationally, it's crucial for nurses to be able to differentiate between physical and mental health symptoms to provide appropriate care. Understanding the nuances of mental health conditions like depression helps nurses in accurately assessing and supporting patients, leading to better outcomes and quality of care.

Correct Answer: A

Rationale: The correct answer is option A because it demonstrates the most concrete evidence of treatment effectiveness. The patient being abstinent for 10 days indicates immediate compliance with the treatment plan. Additionally, stating "I can maintain sobriety one day at a time" reflects a key principle of Alcoholics Anonymous and recovery programs, showing the patient's understanding of their journey. Moreover, the fact that the employer is willing to allow the patient to return to work in 3 weeks suggests positive progress and support from the external environment. Options B, C, and D are incorrect as they each have red flags indicating potential relapse or misalignment with effective treatment outcomes. Option B's statement of "My problems are under control" may indicate overconfidence or denial of ongoing issues. Option C's focus on helping others and finding jobs for them instead of personal recovery suggests a lack of self-awareness. Option D's statement about being able to handle one or two drinks raises concerns about boundaries and potential relapse triggers. In an educational context, this question assesses the nurse's ability to interpret patient progress and treatment effectiveness based on documentation. It highlights the importance of looking for concrete evidence of compliance with treatment plans, understanding of recovery principles, and integration of support systems in evaluating patient outcomes in alcohol treatment programs. By understanding these nuances, nurses can provide more effective care and support to individuals struggling with addiction.

Correct Answer: B

Rationale: In this scenario, option B is the most appropriate response for the nurse to assist the patient in reframing their overgeneralization. By suggesting to explore a specific event to identify alternative explanations, the nurse is guiding the patient towards critical thinking and challenging their automatic negative thoughts. This approach helps the patient recognize that not all bad outcomes are solely their fault, promoting a more balanced perspective. Option A is incorrect because it simply dismisses the patient's belief without offering a constructive alternative. This response may come off as invalidating and not supportive of the patient's feelings. Option C, while showing empathy, does not actively engage the patient in challenging their negative thought pattern. It acknowledges the patient's self-criticism but does not provide a strategy for cognitive restructuring. Option D is unrelated to the patient's statement and does not address the overgeneralization presented. Bringing up the patient's belief in fate or cultural heritage does not directly assist in reframing the negative thought pattern the patient is experiencing. Educationally, this question highlights the importance of active listening and therapeutic communication skills in nursing practice. It emphasizes the role of nurses in guiding patients towards more adaptive thought processes and promoting mental well-being through cognitive restructuring techniques. By understanding the rationale behind each response, nurses can enhance their ability to support patients with mental health challenges effectively.

Correct Answer: D

Rationale: The correct answer is D) Assess for signs of withdrawal. In this scenario, the priority nursing intervention is to assess for signs of withdrawal because the patient is exhibiting symptoms like agitation, sweating, and hand tremors, which are indicative of alcohol withdrawal. Early identification of withdrawal symptoms is crucial in preventing potential complications such as seizures, delirium tremens, or even death. By assessing the patient for signs of withdrawal, the nurse can determine the severity of the withdrawal symptoms and initiate appropriate interventions promptly. Option A) Provide a quiet, calm environment, is important in managing withdrawal symptoms, but it is not the priority at this moment. Option B) Encourage the patient to drink fluids may be beneficial, but it does not address the immediate concern of assessing for withdrawal symptoms. Option C) Administer medications as prescribed may be necessary, but without a thorough assessment of withdrawal symptoms, the nurse may not know which medications are most appropriate for the patient's condition. In an educational context, this question highlights the importance of recognizing and managing alcohol withdrawal in patients. Nurses need to be able to prioritize interventions based on the patient's condition and assess for potential complications. This question reinforces the critical thinking skills required in nursing practice to ensure patient safety and well-being.

Correct Answer: B

Rationale: In this scenario, the correct nursing diagnosis for the patient expressing feelings of failure is option B) Hopelessness. Major depressive disorder often manifests with feelings of hopelessness, helplessness, and worthlessness. By selecting this diagnosis, the nurse acknowledges the patient's emotional state and can initiate appropriate interventions to address these feelings and promote mental health. Option A) Powerlessness may not be the most appropriate diagnosis in this case as the patient is expressing feelings of failure rather than lack of control over their situation. Option C) Imbalanced nutrition: Less than body requirements is not relevant to the patient's statement about feeling like a failure. Option D) Risk for suicide, while important to assess in patients with major depressive disorder, is not the most appropriate initial nursing diagnosis based solely on the patient's statement about feeling like a failure. In an educational context, understanding how to accurately identify and prioritize nursing diagnoses is crucial for providing effective care to patients. By choosing the correct nursing diagnosis, nurses can tailor their interventions to address the specific needs of each individual patient, promoting holistic care and positive patient outcomes.