Major Depression Case Study

Meet the client:
Joan Miller, a 52-year-old sales representative, presents to the community mental health clinic. Joan is divorced with no children. Her position responsibilities include significant traveling. She was working in Manhattan on 9/11 and witnessed the collapse of the World Trade Center.
Joan’s medical history includes hypothyroidism and depression. At this time she has experienced menopause. Surgical history includes an appendectomy at age 23 years.
Currently, Joan is taking the following medications:
escitalopram (Lexapro) 20 mg once a day
estradiol/norethindrone acetate (Activella) 1 tablet 1 mg /0.5 mg once a day
levothyroxine (Synthroid) 125 mcg once a day
Joan tells the nurse that she has been feeling increasingly depressed for a long time. She describes herself as easily irritated, anxious, and as someone who does not enjoy her normal activities.
Using the Sullivan model during the initial assessment, the nurse should focus on which area?
Symptoms of anxiety.
What should the nurse say to elicit the most subjective information from the client?
“Tell me more about your anxiety.”
Joan meets with the APRN-PMH; during the session Joan tells the nurse that she has an extreme amount of stress at work. She has filed multiple harassment complaints against her boss. She states that she feels she has to “hold” herself to a “higher set of standards” than her coworkers because her boss uses a stricter set of standards for her performance appraisal.

The nurse recognizes that Joan is experiencing what level of anxiety?


(The individual with severe anxiety can only focus on a narrowed area of concern, such as Joan only focusing on her employer and coworkers.)

The nurse develops a plan of care to assist Joan in managing her anxiety. Which model or theory is likely to produce the most effective results when treating Joan’s anxiety?
Theory of Social Interaction.

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Joan tells the nurse that she sweats all the time and occasionally has chest pains. She also complains of numbness in her arms and hands. How should the nurse respond to Joan’s comments?
“Tell me more about your chest pain.”
Which nursing diagnosis for the client’s anxiety should the nurse record?
Ineffective coping related to interpersonal conflicts.
Joan tells the nurse that she “believes in doing her job right.” Joan goes on to say that she sees her boss as “out to get me because I am 52 years old.” The nurse further inquires about the statements made by Joan about her feeling regarding the work environment.

Which behavior should the nurse illicit from the client?

Stating the sources for present anxiety.
Joan states that she is worried because she feels she is being singled out because she is the oldest of her coworkers, “Everyone thinks I should be doing better than I am because of my age.”

Which nursing diagnosis should the nurse add to Joan’s plan of care?

Anxiety related to maturational crisis.
Which question or statement by the nurse is most likely to encourage Joan to talk about the issues that are contributing to her anxiety?
“What does being 52 years old mean to you?”
The APRN-PMH changes the client’s antidepressant to bupropion (Wellbutrin XL) 300 mg once a day and orders alprazolam (Xanax) 0.25 mg twice a day prn for the client’s anxiety. When Joan picks up the prescription at the front desk she asks the nurse when to take the Xanax.

How should the nurse answer Joan’s question about when take the Xanax?

“Measure your anxiety on a scale, then decide when to use Xanax, but do not exceed twice a day.”
What information should the nurse discuss with Joan about Wellbutrin XL?
Anxiety level may increase.
Before Joan has the prescription for bupropion (Wellbutrin XL) filled, the nurse should ensure that the client has not experienced which problem(s)?
Anorexia or bulimia. Seizures.
While the nurse is teaching the client about taking Wellbutrin XL, Joan asks if it is all right to drink alcohol when taking the medication. How should the nurse respond to Joan’s question?
Do not consume alcohol while taking the medication.
Although Xanax is ordered as 0.25mg, when Joan goes to the pharmacy to pick up the prescriptions, the Xanax is only available as 0.5 mg at this time. How many tablet(s) should the nurse instruct Joan to take with each dose? (Enter numerical value only. If rounding is necessary, round to the whole number.)
0.5 tablet
Several days after starting the medication, Joan calls the office and tells the nurse that the Wellbutrin XL is giving her headaches. How should the nurse respond to Joan’s complaint of headaches?
“The headaches usually go away within a few days.”
What is the most important question the nurse should ask the client once the client is taking the medication Wellbutrin XL?
“Have you had any suicide thoughts since starting Wellbutrin XL?”
After 4 weeks of therapy, Joan calls the clinic’s emergency line. She is crying and reports that she “has nothing to live for.” Which question should the nurse ask Joan first?
How do you plan to hurt yourself?
During the conversation with the nurse on the clinic’s emergency line Joan tells the nurse that she has thought about taking an overdose. She tells the nurse that she has prescriptions for Xanax, and Wellbutrin XL. The nurse knows that an overdose of this combination of drugs could be lethal.

How should the nurse respond to Joan?

“Go to the hospital now because this is a serious situation.”
Joan is admitted to the hospital for 5 days. She returns to the mental health clinic for a follow-up visit. She is now on 10 mg escitalopram (Lexapro) at bedtime and 150 mg bupropion (Wellbutrin XL) in the morning.

Which statement by the client best suggests that the medication combination is working?

“The things that happen at work don’t bother me so much.”
Six months after her initial presentation, Joan comes to the clinic for her regular visit. While waiting to be seen she tells the RN-PMH that she wants to stop taking her medication.

How should the nurse respond to the client’s statement?

“Most clients do better by taking the medicine for a year.”
It has now been 1 year since Joan’s initial presentation to the clinic. The APRN-PMH is conducting her regular follow-up interview with Joan and listening to Joan describe her work situation. The nurse recognizes that the client is using reaction formation as a defense mechanism.

On which statement by the client is the nurse basing this assessment?

“I just tell the boss that nothing she does will upset me.”
The nurse knows that Joan is still easily upset by her boss’ behavior. How should the nurse respond to Joan?
“How do you feel when your boss says something that upsets you?”
The nurse is concerned about Joan’s apparent continuing difficulties with her boss. In considering Joan’s statements about her interactions with her boss, which standard of the ANA Psychiatric – Mental Health Nursing care should the nurse apply to the current sit
Joan is discharged from the clinic program after 6 more months because she feels she recognizes what aspects of her work caused her anxiety and she is able to deal with these problems at her job. The nurse-client relationship is terminated with Joan’s discharge from the mental health clinic.

What makes termination important to the nurse-client relationship?

Termination teaches the client to resume a normal lifestyle.
Eight months after being discharged from the clinic, Joan calls the clinic and “wants to talk.”

How should the nurse respond to Joan’s request?

Instruct the client to make an appointment for follow-up.
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