Question

A nurse is assessing a 38-year-old client diagnosed with major depressive disorder (MDD). The client states: "I am worthless and a failure. Nothing good ever happens to me, and I will never feel better." Which concept of Beck's cognitive triad is demonstrated in this client's statements?

Answer 1

Correct Answers:

Negative view of the self, the world, and the future

Rationale :

💎 Cognitive triad: Beck’s theory states that depression results from negative automatic thoughts about oneself (“I’m worthless”), the world (“Nothing good ever happens”), and the future (“I’ll never feel better”).

💎 Core distortion: These maladaptive beliefs reinforce hopelessness and helplessness, maintaining depressive mood.

💎 Assessment clue: The pattern of self-blame and despair directly reflects the triad, not psychosis or physical symptoms.

💎 Therapeutic care: Cognitive-behavioral therapy (CBT) challenges these irrational beliefs and fosters realistic thinking.

💎 Outcome focus: Helping clients restructure cognition reduces relapse and improves mood regulation.

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Answer 2

Correct Answers:

"Children as young as 3 years of age have been diagnosed with depression."

Rationale :

🔷 Prevalence trends: Depression affects all age groups, and early-onset depression has become increasingly recognized due to improved awareness and diagnostic criteria.

🔷 Childhood depression: Can manifest as irritability, somatic complaints, or withdrawal, not always sadness.

🔷 Clinical significance: Early detection prevents chronic mood disorders and suicide risk later in life.

🔷 Epidemiology: The lifetime prevalence of MDD is rising due to socioeconomic stressors and cultural changes.

🔷 Nursing implication: Be alert for nonverbal signs of depression in children and ensure supportive family education.

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Answer 3

Correct Answers:

Display a firm, calm approach.

Rationale :

💠 Mania behavior: Clients are often hyperactive, impulsive, and distractible, requiring structured calm communication.

💠 Nursing approach: A firm, consistent tone and clear limits reduce overstimulation and prevent escalation.

💠 Safety: Protect client from self-harm or exploitation; restrict access to valuables and limit stimuli.

💠 Avoid: Lengthy explanations—clients in mania have short attention spans and poor concentration.

💠 Goal: Promote rest, nutrition, and decrease environmental triggers.

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Answer 4

Correct Answers:

Sitting quietly with the client, allowing them time to respond or remain silent

Rationale :

🟢 Therapeutic silence: Demonstrates acceptance and presence, allowing the client to process and feel supported.

🟢 Depressive psychomotor slowing: Clients with severe depression need extra time to respond due to slowed thinking.

🟢 Avoid pressure: Forcing speech increases anxiety and guilt; silence communicates respect and empathy.

🟢 Nonverbal support: A calm, nonjudgmental presence strengthens trust.

🟢 Nursing action: Use simple statements and allow pauses; silence can be healing.

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Answer 5

Correct Answers:

Concurrent use of St. John's wort
Initiating phenelzine (Nardil)
Administration of Robitussin Cough Medicine

Rationale :

🔶 St. John’s Wort: Herbal antidepressant that increases serotonin levels; combining with SSRIs like Zoloft can cause serotonin syndrome.

🔶 Phenelzine (Nardil): An MAOI; concurrent use with SSRIs is contraindicated due to risk of hypertensive crisis and serotonin toxicity (must allow a 14-day washout).

🔶 Robitussin (dextromethorphan): Common OTC cough syrup; potentiates serotonin and may trigger serotonin syndrome when taken with SSRIs.

🔶 ECT: Safe with SSRIs and can be effective in treatment-resistant depression.

🔶 Nursing focus: Monitor for serotonin syndrome signs—confusion, hyperreflexia, fever, tremor, and diaphoresis.

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Answer 6

Correct Answers:

Ensuring the client has a safe environment by removing potentially harmful objects.
Encouraging the client to rest and eat regularly, monitoring hydration and nutrition.
Documenting the client's behavior thoroughly, including any impulsive or aggressive actions, to meet legal requirements.
Using calm, concise communication, setting clear limits, and explaining consequences of unsafe behaviors.

Rationale :

💎Safe environment: Clients in mania are impulsive and risk-prone; removing harmful or breakable objects prevents accidental or intentional injury.

💎Rest and hydration: Manic clients often neglect eating and sleeping; monitoring nutrition and fluids prevents exhaustion and dehydration.

💎Documentation: Thorough, factual documentation of impulsive or aggressive acts is essential for legal protection and continuity of care.

💎 Calm, concise limits: Firm but kind communication and clear boundaries reduce escalation and preserve therapeutic control.

💎 Allowing financial access increases risk of reckless spending or exploitation.

💎 Neglecting hygiene can worsen infection and self-esteem issues.

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Answer 7

Correct Answers:

Serum creatinine 2.01 mg/dL

Rationale :

🔷 Renal clearance: Lithium is excreted unchanged by the kidneys; impaired renal function leads to toxic accumulation.

🔷 Normal range: Serum creatinine should be 0.6–1.3 mg/dL; 2.01 indicates renal insufficiency.

🔷 Toxic risk: In renal impairment, even therapeutic doses can quickly rise to toxic levels (>1.5 mEq/L).

🔷 Other labs: Sodium 135 (normal), T3/T4 slightly low (monitor thyroid), glucose 120 (not a contraindication).

🔷 Nursing action: Report to provider; hold lithium until renal status is clarified.

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Answer 8

Correct Answers:

It is a normal level and does not require additional nursing intervention.

Rationale :

💠 Therapeutic range: Maintenance lithium level is 0.6–1.2 mEq/L; 1.16 is within normal range.

💠 Timing: Blood sample drawn 8–12 hours after last dose ensures accurate trough reading.

💠 Monitor ongoing: Continue regular checks for toxicity signs—tremor, confusion, vomiting.

💠 Client teaching: Encourage adequate fluid and sodium intake to maintain balance.

💠 Toxic level: Above 1.5 mEq/L requires dose adjustment; >2.0 = medical emergency.

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Answer 9

Correct Answers:

"Light therapy helps regulate serotonin and circadian rhythms that affect mood."

Rationale :

🟢 Mechanism: Phototherapy mimics daylight, regulating serotonin and melatonin, balancing mood and sleep–wake cycles.

🟢 Indication: Used for seasonal affective disorder (SAD), where reduced sunlight decreases serotonin and disrupts circadian rhythm.

🟢 Therapeutic action: Restores biochemical balance and improves energy, mood, and concentration.

🟢Light decreases, not increases, melatonin. Dopamine/endorphin modulation isn’t the primary effect.

🟢 Safety: Use in morning for 30–45 min; avoid direct eye exposure.

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Answer 10

Correct Answers:

It encourages nurses to approach clients with empathy and avoid minimizing their emotional suffering.

Rationale :

🔶 Core principle: Depression involves profound emotional pain; understanding it promotes empathy, patience, and nonjudgmental care.

🔶 Therapeutic presence: Empathy builds trust and encourages clients to express suicidal or hopeless thoughts safely.

🔶 Avoid minimization: Statements like “everyone feels sad” invalidate feelings and worsen isolation.

🔶 Holistic care: Effective management integrates emotional support, pharmacologic therapy, and psychoeducation.

🔶 Outcome: Empathetic nurses foster hope and engagement in recovery.

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QLexNursing

1 :
A nurse is assessing a 38-year-old client diagnosed with major depressive disorder (MDD). The client states: "I am worthless and a failure. Nothing good ever happens to me, and I will never feel better." Which concept of Beck's cognitive triad is demonstrated in this client's statements?

4 :
A nurse is caring for a client with severe major depressive disorder. The client speaks very slowly and occasionally remains mute. The nurse feels uncomfortable with the silence during the interaction. Which of the following actions demonstrates the most therapeutic approach in this situation?

5 :
A nurse is caring for a 45-year-old client diagnosed with major depressive disorder who has been taking Sertraline (Zoloft) for the past 3 weeks. Which of the following treatments or medications would be contraindicated for this client? (Select all that apply.)

8 :
A nurse reviewing the laboratory results for a client diagnosed with bipolar disorder notes the lithium level as 1.16 mEq/L, taken 8 to 12 hours after the last dose of lithium. What will be the most appropriate nurse intervention depending on how nurse interpret this information?

9 :
A nurse is educating a client with major depressive disorder with a seasonal pattern about light therapy (phototherapy). Which statement by the nurse best explains why light therapy is indicated for this condition?

QLexNursing

1 : A nurse is assessing a 38-year-old client diagnosed with major depressive disorder (MDD). The client states: "I am worthless and a failure. Nothing good ever happens to me, and I will never feel better." Which concept of Beck's cognitive triad is demonstrated in this client's statements?

4 : A nurse is caring for a client with severe major depressive disorder. The client speaks very slowly and occasionally remains mute. The nurse feels uncomfortable with the silence during the interaction. Which of the following actions demonstrates the most therapeutic approach in this situation?

5 : A nurse is caring for a 45-year-old client diagnosed with major depressive disorder who has been taking Sertraline (Zoloft) for the past 3 weeks. Which of the following treatments or medications would be contraindicated for this client? (Select all that apply.)

8 : ​A nurse reviewing the laboratory results for a client diagnosed with bipolar disorder notes the lithium level as 1.16 mEq/L, taken 8 to 12 hours after the last dose of lithium. What will be the most appropriate nurse intervention depending on how nurse interpret this information?

9 : ​A nurse is educating a client with major depressive disorder with a seasonal pattern about light therapy (phototherapy). Which statement by the nurse best explains why light therapy is indicated for this condition?

1 :
A nurse is assessing a 38-year-old client diagnosed with major depressive disorder (MDD). The client states: "I am worthless and a failure. Nothing good ever happens to me, and I will never feel better." Which concept of Beck's cognitive triad is demonstrated in this client's statements?

4 :
A nurse is caring for a client with severe major depressive disorder. The client speaks very slowly and occasionally remains mute. The nurse feels uncomfortable with the silence during the interaction. Which of the following actions demonstrates the most therapeutic approach in this situation?

5 :
A nurse is caring for a 45-year-old client diagnosed with major depressive disorder who has been taking Sertraline (Zoloft) for the past 3 weeks. Which of the following treatments or medications would be contraindicated for this client? (Select all that apply.)

8 :
A nurse reviewing the laboratory results for a client diagnosed with bipolar disorder notes the lithium level as 1.16 mEq/L, taken 8 to 12 hours after the last dose of lithium. What will be the most appropriate nurse intervention depending on how nurse interpret this information?

9 :
A nurse is educating a client with major depressive disorder with a seasonal pattern about light therapy (phototherapy). Which statement by the nurse best explains why light therapy is indicated for this condition?