HESI Case Studies–Psychiatric/Mental Health-Depression (Anna Gray)
1. What question should the nurse ask as a priority nursing assessment?
“What is the voice saying to you?”
2. How many points does Anna have?
3. Which behavior is inconsistent with depression?
Hearing a man’s voice
4. If the client refuses treatment, which behavior(s) justify short-term involuntary treatment? (Select all)
-Unable to meet basic self-care needs
-States she has a plan to harm herself
5. In what classification of drugs is the antidepressant fluoxetine (Prozac)?
Selective serotonin reuptake inhibitor (SSRI)
6. What is the major action of SSRI antidepressants?
Increase availability of serotonin
7. The nurse understands that SSRIs are now more widely prescribed than tricyclics for antidepressant therapy. What is the rationale?
Tricyclics are more lethal in an overdose
8. When should the client begin to feel less depressed?
1 to 3 weeks
9. Which side effects commonly occur in clients who are taking SSRI antidepressants?
10. Which explanation is best?
“This medication will help you think more clearly.”
11. The nurse understands that a VDRL is routinely done on admission for which reason?
It is a screening test for syphilis
12. What role do thyroid levels play in depression?
Hypothyroidism can lead to feeling sluggish and depressed
13. Which intervention is important?
Help the client with daily activities
14. Since the client has decreased energy, which intervention is best?
Plan a scheduled rest period
15. As the nurse initially communicates with Anna, which communication technique is important?
Reinforce that she will progressively feel better
16. According to this data, what is the priority nursing problem?
17. Since Anna is eating 50% of her meals, which priority nursing intervention should be included on the treatment plan?
Weigh weekly and document
18. Which DSM-V axis would the nurse use to interpret for the presence of hypertension?
19. Which recommendation is best to minimize the risk of hypertension?
No added salt in diet
20. Which risk factor does Anna have?
21. One morning the nurse is ding unit rounds and finds Anna sitting at the edge of her bed with a sheet around her neck. What is the first nursing action?
Stay with Anna
22. When Anna wants to change clothes and get ready for sleep at night, what should the staff do?
Keep the door to Anna’s room open
23. Which staff member is best to assign to Anna?
Unlicensed female counselor
24. What should the nurse do?
Pour the soft drink into a paper cup
25. What is the best predictor of safety?
Anna agrees to talk with staff if thoughts of self-harm occur
26. Which information should be included in the teaching plan?
Headache, nausea, and muscle aches may occur after the treatment
27. When the nurse prepares a client for ECT, what should be expected?
Preparation is similar to brief surgical procedure
28. When Anna awakens from the treatment, the nurse should be prepared to perform which nursing action?
Take vital signs and assess orientation
29. What signs and symptoms should the nurse expect to assess if a client taking an MAO antidepressant ingests foods containing tyramine?
Headache and palpitations
30. Which food would be considered safe?
31. Which specific nursing consideration is most important?
Maintain a low-tyramine or tyramine-free diet for 10 to 14 days