14 what is the focus of priority nursing

This preview shows page 8 - 11 out of 16 pages.

cheese, yeast, caffeine drinks, and chocolate.14. What is the focus of priority nursing interventions for the period immediately afterelectroconvulsive therapy treatment?A. Supporting physiologic stabilityANS: ADuring the immediate post-treatment period, the patient is recovering from general anesthesia,hence the need to establish and support physiologic stability. Monitoring pupillary responsesis not a priority. Reducing disorientation and confusion is an acceptable intervention but notthe priority. Assisting the patient in identifying and testing negative thoughts is inappropriate in the immediate post-treatment period because the patient may be confused.15. A nurse provided medication education for a patient who takes phenelzine (Nardil) fordepression. Which behavior indicates effective learning? The patient:C. consults the pharmacist when selecting over-the-counter medications.ANS: COver-the-counter medicines may contain vasopressor agents or tyramine, a substance thatmust be avoided when the patient takes MAOI antidepressants. Medications for colds,allergies, or congestion or any preparation that contains ephedrine or phenylpropanolaminemay precipitate a hypertensive crisis. MAOI antidepressant therapy is unrelated to the need
Background image
for sodium limitation, support stockings, or leg elevation. MAOIs interact withtyramine-containing foods, not selenium, to produce dangerously high blood pressure.16. A patient’s employment is terminated and major depressive disorder results. The patient says to the nurse, “I’m not worth the time you spend with me. I’m the most useless person in theworld.” Which nursing diagnosis applies?C. Situational low self-esteemANS: CThe patient’s statements express feelings of worthlessness and most clearly relate to thenursing diagnosis of Situational low self-esteem. Insufficient information exists to justify the other diagnoses.17. A patient diagnosed with major depressive disorder does not interact with others except whenaddressed and then only in monosyllables. The nurse wants to show nonjudgmentalacceptance and support for the patient. Select the nurse’s most effective approach tocommunication.A. Make observations.ANS: AMaking observations about neutral topics such as the environment draws the patient into thereality around him or her but places no burdensome expectations on the patient for answers.Acceptance and support are shown by the nurse’s presence. Direct questions may make thepatient feel that the encounter is an interrogation. Open-ended questions are preferable if the patient is able to participate in dialog. Platitudes are never acceptable; they minimize patient feelings and can increase feelings of worthlessness.
Background image
18. A patient being treated for major depressive disorder has taken 300 mg amitriptyline (Elavil) daily for a year. The patient calls the case manager at the clinic and says, “I stopped taking my antidepressant 2 days ago. Now I am having cold sweats, nausea, a rapid heartbeat, andnightmares.” The nurse should advise the patient:
Background image
Image of page 11

You've reached the end of your free preview.

Want to read all 16 pages?

  • Fall '19
  • Selective serotonin reuptake inhibitor, Major depressive disorder, Antidepressant

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture

  • Left Quote Icon

    Student Picture