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Situation: B., age 42, is brought to the hospital by her husband, who reports that she has been neglecting her housework and family responsibilities and eating very little and has not left the house for the past 2 months. She is 5'7" (170 cm) tall and normally weighs 147 lbs. (66.7kg), but during the past 8 weeks, she has lost 20 lb (9.1kg). Mrs. B.'s history reveals that her 7 months old daughter recently died of sudden infant death syndrome (SIDS). She is admitted to the psychiatric unit with a diagnosis of depression.
1. Immediately after admission, B. isolates herself in her room. The nurse should approach the patient with the understanding that:
a) depressed patients like B. commonly are suicidal and establishing a trusting relationship is key to preventing suicide
b) B. probably believes she is not ill and therefore will not socialize with others at this point
c) B. is isolating herself because her family is not available to support her
d) B.'s illness and hospitalization for emotional problems have a negative impact on her and her family
2. The nurse helps B. to settle in. While observing B. unpack, the nurse expects her to exhibit:
a) fast, hurried movements
b) slow, restarted movements
c) a desire to initiate a conversation with her roommates
d) a desire to unpack and arrange her belongings without assistance
3. Early that evening, B. tearfully tells the nurse, "I feel so guilty. I left the window open in my daughter's room. Maybe she got chilled during the night. Perhaps the crib should have been on the other side of the room." How should the nurse respond?
a) you're still young. You and your husband can have another child if you want
b) I don't think that's what caused your daughter's death. You have other children you should be concerned about
c) you shouldn't feel guilty, B. Why don't you try to forget about such sad memories
d) your daughter died of SIDS B. It was not your fault
4. The following day, the nurse finds B. pacing the hallways, wringing her hands, picking at her hair and skin and saying, "I don't know what to do. I don't know what to do." The most appropriate nursing action at this time is to:
a) take the patient back to her room and encourage her to rest
b) calmly tell the patient to pull herself together
c) encourage the patient to help water the plant in the dayroom
d) permit the patient to continue her behavior until she eels less anxious
5. After 1 week, B. states, "Now that my baby is dead and I'm too old to have another one, I don't want to live anymore." The nurse should respond by saying:
a) life doesn't look very promising to you right now, but let's talk about this
b) you shouldn't feel so hopeless. many women are having babies in their forties
c) I care about you, and I want you to live
d) What about your husband and other children? Don't you think they need you?
6. B. is started on imipramine (tofranil) 75 mg orally at bedtime. The nurse should tell the patient that:
a) the medication may be habit forming, so it will be discontinued as soon as she feels better
b) the medication has no serious side effects
c) she should avoid eating such foods as aged cheeses, yogurt, and chicken livers while taking the medication
d) the medication may initially cause some tiredness, which should become less bothersome over time
7. The nurse should inform B. that the full therapeutic benefits of imipramine may not take effect for:
a) 3 to 7 days
b) 2 to 3 weeks
c) 3 to 4 weeks
d) 2 months or more
8. B. does not respond to the medication. At a team conference, staff members recommend electroconvulsive therapy (ECT). When should nursing interventions begin?
a) as soon as the patient and her family are presented with this treatment alternative
b) the night before ECT scheduled
c) immediately after ECT is administered
d) when the patient returns to the unit after ECT therapy
ANSWERS AND RATIONALE
2) B
- the behavior of the depressed patient is typically slow, retarded, and fatiguing. Such a patient also has difficulty interacting, making decisions, and initiating independent actions. Nursing interventions should be planned to assist and support the patient as needed to meet her needs. Although increased activity may be observed in patients with agitated depression (depression with frantic pacing), it is more common in those with mania.
3) D
- the nurse should restate and reinforce that the child's death was not B.'s fault, nor was it related to her actions. Sudden infant death syndrome strikes unexpectedly; it has no symptoms or warning signs. Denying the patient's feelings of loss is both nontherapeutic and insensitive.
4) C
- a simple task like the plants provides a purposeful activity to focus the patient's energy as well as human contact and a sense of accomplishment. By encouraging assistance in this activity, the nurse attempts to increase B.'s self-esteem. Isolating the patient in her room, telling her to pull herself together, and ignoring her distress by not intervening are nontherapeutic aprroaches.
5) A
- reflecting the patient's feeling by responding :Life doesn't look very promising right now..." validates how the patient feels and encourages her to ventilate further. Although the nurse should let the patient know that she cares and will protect her, such responses as "You shouldn't feel so hopeless," "What about your husband and children," or even simply "I care" deny the patient's feelings, cut her off, and shift the focus to how others feel. The nurse should provide an opportunity for the patient to express her feelings.
6) D
- sedation is a common early side effect of the tricyclic antidepressant imipramine (tofranil) and usually decreases as tolerance develops. Antidepressants are not habit forming; do not cause physical or psychological dependence. However, after they are taken at high doses for long periods, the dosage should be decreased gradually to avoid mild withdrawal symptoms. Serious side effects, although rare, can occur; they include myocardial infarction, congestive heart failure, and tachycardia. Dietary restrictions, such as avoiding aged cheeses, yogurt, and chicken livers, are necessary for a patient taking monoamine oxidase (MAO) inhibitors, not tricyclic antidepressants.
7) C
- antidepressant agent such as imipramine usually produce a noticeable effect in 2 to 3 weeks but do not reach full therapeutic effectiveness until 3 to 4 weeks after initiation of therapy. If no improvement is noted by that time, the medication is considered ineffective and a new drug is tried. The nurse must be sure to teach the patient that the drug's effect will occur gradually and that discontinuing it before peak effectiveness is achieved will render the drug useless. She also must encourage and support the patient during this time because the depressed patient may expect more immediate relief from the medication.
8) A
- the nurse is responsible for assessing the patient's and family members' response to electroconvulsive therapy (ECT) and for providing opportunities for communication regarding their feelings and concerns as soon as the treatment is proposed. ECT is rarely an initial treatment for depression; it is used when a patient responds poorly to medication. It involves inducing a seizure in the patient by passing electric current through the brain (seizures are thought to produce changes in neurotransmitters and receptor sites similar to those produced by antidepressant medications). Before the treatment, the patient is given a short-acting barbiturate to induce anesthesia. After the procedure, the patient typically awakens quickly but remains confused and light-headed, necessitating close nursing supervision until these effects subside.
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