The nurse is performing a focused interview with an older adult client. Which of the following statements indicate the client has an increased risk of developing depression? Standard Text: Select all that apply
1. "I've been so lonely since my wife, Maggie, passed away 2 months ago.".
2. "My mother had a history of depression.".
3. "I was diagnosed with chronic bronchitis 4 years ago.".
4. "My son visits at least once a week and takes care of my financial stuff.".
5. "I visit my sister every Monday and she makes me dinner.".
1,2,3
Rationale 1: "I've been so lonely since my wife, Maggie, passed away 2 months ago.". Loneliness is a risk factor for the development of depression.
Rationale 2: "My mother had a history of depression.". A family history of depression increases the client's risk.
Rationale 3: "I was diagnosed with chronic bronchitis 4 years ago.". Chronic illnesses such as chronic bronchitis increases the client's risk for becoming depressed.
Rationale 4: "My son visits at least once a week and takes care of my financial stuff.". This client's son visits. The client has evidence of a social support system.
Rationale 5: "I visit my sister every Monday and she makes me dinner.". The client visits a sibling each week and shares a meal with the sibling. This is more evidence of the presence of a social support system.
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A client with hypertension stops into the clinic for a weekly blood pressure and blood glucose measurement along with a full set of vital signs
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Ten minutes after the transfusion of a unit of packed red blood cells was initiated, the client complains of a headache. The nurse assesses that the client has slight shortness of breath and feels warm to the touch. What action by the nurse is priority?
1. Notify the client's physician. 2. Discontinue the transfusion. 3. Slow the rate of the transfusion. 4. Prepare to resuscitate the client.