During the admission assessment of a new client, which of the following factors should alert the nurse to possibility that the client is depressed and further evaluation is necessary? Standard Text: Select all that apply
1. The client reports a history of rheumatoid arthritis and type 2 diabetes, which are both well controlled.
2. The client has been late for work several times due to oversleeping during the last month.
3. The client reports a family history of depression.
4. The client has had difficulty falling asleep for the last 7 days.
5. The client reports a generalized feeling of muscle aches that have occurred over the last 3 weeks.
2,3,5
Rationale 1: The client reports a history of rheumatoid arthritis and type 2 diabetes, which are both well controlled. Well-controlled chronic illnesses that cause no impairment in social or work functioning is not an indication of depression. Two or more chronic illnesses with impairment in social or work functioning are one of the series of symptoms that may indicate depression and warrants further evaluation.
Rationale 2: The client has been late for work several times due to oversleeping during the last month. Depression is indicated if a client reports a series of symptoms that have persisted for more than 2 weeks and have caused impairment in social and/or work functioning. Fatigue and a disturbance in sleep patterns for 3 weeks may indicate depression and warrants further evaluation of the client.
Rationale 3: The client reports a family history of depression. A family history of depression is one factor that can contribute to depression, warranting further evaluation of the client.
Rationale 4: The client has had difficulty falling asleep for the last 7 days. A disturbance in sleep patterns for more than 2 weeks is one of the symptoms of depression. This client reports difficulty falling asleep for only 7 days.
Rationale 5: The client reports a generalized feeling of muscle aches that have occurred over the last 3 weeks. Depression is indicated if a client reports a series of symptoms that have persisted for more than 2 weeks and have caused impairment in social and/or work functioning. Multiple vague symptoms such as generalized aches are one of the symptoms. This client reports that these symptoms have lasted for 3 weeks; therefore, further evaluation for depression is warranted.
You might also like to view...
The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
a. Severity of the symptoms b. Site of the lesions c. Symptomatology of the lesions d. Surface area of the lesions
As a result of Amy's coaching, Sarah, a nursing graduate of 5 years, completes a ROLES assessment. This assessment is helpful in (select all that apply):
a. Identifying her clinical knowledge. b. Role development. c. Areas of conflict in expectations. d. Expected work time commitments.
The client reports the presence of lower right abdominal pain for 2 days and, on examination, the client's abdomen is rigid, with tense positioning. What conclusion can the nurse draw from this information?
A. The client is experiencing an adverse reaction to opioids. B. The client is experiencing an exacerbation of Crohn's disease. C. The client is experiencing a remission of appendicitis symptoms. D. The client is experiencing perforation of the appendix and peritonitis.
A newly employed nurse had read the nurse practice act very carefully. After the first orientation day, the nurse read the agency procedure book from cover to cover and discovered
that some policies seemed to be contradictory to the state law. What should the nurse do? A. Ask the agency supervisor what the nurse should do. B. Ask the physician what the physician wanted done in areas where there were discrepancies. C. Follow agency policy and procedure as the agency was paying the nurse to do. D. Report the discrepancies to the agency and volunteer to help revise the policy.