A nurse is caring for a patient diagnosed with major depressive disorder. The patient expresses feelings of hopelessness, stating, 'I don't think things will ever improve.' What is the priority nursing action?

Correct Answer: C

Rationale: In this scenario, the priority nursing action is option C: Assess the patient for suicidal thoughts and plans. This is the correct answer because when a patient with major depressive disorder expresses feelings of hopelessness, it raises concerns about the risk of suicide. Assessing for suicidal ideation is crucial to ensure the patient's safety and provide appropriate interventions. Option A is incorrect because while positive affirmations and encouragement are important, they are not the priority when there are concerns about suicidal ideation. Option B is also incorrect as participation in group therapy and social activities may be beneficial but does not address the immediate risk of harm to the patient. Option D is incorrect as suggesting the patient avoid thinking about the future does not address the underlying issue of suicidal thoughts. In an educational context, it is essential for nurses to recognize the importance of assessing for suicidal ideation in patients with major depressive disorder. This skill is vital in providing safe and effective care for individuals experiencing mental health challenges. By prioritizing the assessment of suicidal thoughts, nurses can intervene promptly and prevent potential harm to the patient.

Correct Answer: B

Rationale: Eustress is beneficial stress; it motivates people to develop skills they need to solve problems and meet personal goals. Positive life experiences produce eustress. Going on a tropical vacation is an exciting, relaxing experience and is an example of eustress. Losing the family pet, worrying about employment security, and having financial problems are examples of distress, a negative experience that drains energy and can lead to significant emotional problems.

Correct Answer: D

Rationale: In this scenario, the most appropriate question for the nurse to ask the patient with a tentative diagnosis of generalized anxiety disorder is option D: "Do you find it difficult to control your worrying?" This question is the most suitable as it directly addresses a key symptom of generalized anxiety disorder, which is excessive and uncontrollable worrying. Option A is incorrect because it pertains more to post-traumatic stress disorder rather than generalized anxiety disorder. Option B is more indicative of social anxiety disorder, which is a different condition from generalized anxiety disorder. Option C is characteristic of obsessive-compulsive disorder, not generalized anxiety disorder. Educationally, understanding the rationale behind selecting the correct question is crucial for nurses in assessing and differentiating various mental health conditions. By asking targeted questions related to specific symptoms, nurses can provide more accurate assessments, leading to appropriate interventions and support for patients with mental health issues. This approach enhances patient care and ensures proper management of conditions like generalized anxiety disorder.

Correct Answer: A

Rationale: Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis that most likely applies to an adult who is socially withdrawn and hoards is "A) Ineffective home maintenance." This diagnosis is appropriate because the individual's behaviors indicate difficulties in maintaining a safe and healthy living environment due to social withdrawal and hoarding tendencies. Option B, "Situational low self-esteem," and option C, "Chronic low self-esteem," are incorrect in this context because the symptoms described do not directly point to self-esteem issues. While low self-esteem can contribute to behavioral health issues, the primary concern in this case is the individual's ability to maintain their living environment. Option D, "Disturbed body image," is also incorrect because this diagnosis is typically associated with perceptions related to one's physical appearance, which is not the primary concern indicated by the individual's behavior of social withdrawal and hoarding. From an educational perspective, understanding how to analyze behavioral symptoms and connect them to appropriate nursing diagnoses is crucial for effective patient care. Nurses need to be able to assess behaviors, understand their implications, and apply appropriate diagnoses to provide targeted interventions and support for individuals experiencing mental health challenges.