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Meet the Client: Anna Gray

Anna Gray is a 52-year-old African-American widowed female who is accompanied to the

Emergency Department by her daughter. The client's grooming and hygiene are fair, but her
overall appearance is disheveled. Anna's motor activity is slow, she rarely makes eye contact, and
her responses to questions are slow and barely audible. When asked what she prefers to be
called, she replies, "I don't care."
Initial Assessment
The nurse completes a physical assessment. When asked what brought her to the hospital, Anna
replies, "Things just aren't right" and begins to cry. After further conversation, Anna describes
her mood as "very sad now." She rarely goes out or invites friends to visit. She admits that she
feels like strangers are saying bad things about her. Sometimes she hears a man's voice that is a
"little bit scary."
What question should the nurse ask as a priority nursing assessment?
A) "What is the voice saying to you?"
B) "How long have you been hearing the voice?"
C) "Have you ever been hospitalized for depression?"
D) "Where do you see these strangers?"
Assessment of Depression
The daughter, an only child who is visiting from out of town, offers additional information about
Anna's behaviors. The client's clothes fit looser and weight loss is evident. Current alcohol use is
suspected, and a breathalyzer is positive for alcohol use. Anna denies current suicidal ideation,
but the nurse recognizes that the client has risk factors for suicide based on the SAD PERSONS
scale. The SAD PERSONS scale identifies ten categories, and one point is assigned for each
applicable category.
S = Sex. Men kill themselves more often than women, although women make more attempts.
A = Age. High-risk groups include 19-years-old or younger; 45-years-old or older, especially the
elderly of 65-years or older.
D = Depression. Many of those who attempt suicide manifest a depressive syndrome.
P = Previous attempts. Of those who commit suicide, many have made previous attempts.
E = ETOH. Alcohol use is associated with up to 65% of suicides.
R = Rational thinking loss. People with psychoses are more likely to commit suicide than those
in the general population.
S = Social supports lacking. A suicidal person often lacks significant others, meaningful
employment, and other supports. These areas should be assessed.
O = Organized plan. The presence of a specific plan (date, place, means) signifies a person at
high risk.
N = No spouse. Persons who are widowed, separated, divorced, or single are at greater risk than
those who are married.

S = Sickness. Severe illness is a significant risk factor.The following scale is used to score and
interpret the points.
0-2 points Treat at home with follow-up care.
3-4 points Closely follow up and consider possible hospitalization.
5-6 points Strongly consider hospitalization.
7-10 points Hospitalize.
How many points does Anna have?
A) Four
B) Five.
C) Six.
D) Seven.
Anna is assessed by the nurse, social worker, and healthcare provider. Based on their
assessments, hospitalization is recommended for psychotic depression.
Which behavior is inconsistent with depression?
A) Hearing a man's voice.
B) Poor concentration.
C) Poor grooming and hygiene.
D) Slow motor activity.
The nurse must ask the client to sign consent for treatment.
If the client refuses treatment, which behavior justifies short-term involuntary treatment?
A) Unable to meet basic self-care.
B) Experiencing auditory hallucinations.
C) Living alone and lack of social support.
D) Prior hospitalizations for depression.
Anna signs the treatment form and is admitted to the mental health unit. During the first days of
hospitalization, she begins antidepressant therapy with Prozac, 10 mg.
What classification of drugs is the antidepressant fluoxetine (Prozac)?

A) Tricyclic.
B) Selective serotonin reuptake inhibitor (SSRI).
C) Nonbenzodiazepine.
D) Atypical.
What is the major action of SSRI antidepressants?
A) Enhance GABA.
B) Potentiate serotonin and norepinephrine.
C) Increase availability of serotonin.
D) Stimulate the release of serotonin.
The nurse understands that SSRIs are now more widely prescribed than tricyclics for
antidepressant therapy.
What is the rationale?
A) Tricyclics are more lethal in an overdose.
B) SSRIs are less likely to be abused.
C) Tricyclics are less potent than SSRIs.
D) SSRIs more effectively treat depression.
When the client receives fluoxetine (Prozac), the nurse must explain the purpose and when to
expect therapeutic effectiveness.
When should the client begin to feel less depressed?
A) 4 weeks.
B) 3 to 4 days.
C) 1 to 3 weeks.
D) 6 weeks.
The nurse should be aware of common side effects of SSRI antidepressants such as Prozac.
Which side effects commonly occur in clients who are taking SSRI antidepressants?
A) Anticholinergic effects.
B) Extrapyramidal side effects.
C) Gastrointestinal disturbances.
D) Neuroleptic malignant effects.

The client also begins an atypical antipsychotic, risperidone (Risperdal), because she reported
hearing a "scary voice" upon admission. Although the client remains very withdrawn and
noncommunicative, the nurse must explain the purpose of Risperdal.
Which explanation is best?
A) "This medication will help you think more clearly."
B) "Several medications can help you sleep better."
C) "This will control impulsive feelings you may experience."
D) "It will enhance the effectiveness of the antidepressant."
Routine Admission Lab
The nurse is reviewing Anna's admission lab work on the third day of hospitalization. Admission
labs includes thyroid profile, urinalysis, chemistry panel, pregnancy test, urine drug screen, and
The nurse understands that a VDRL is routinely done on admission for which reason?
A) Routine screenings for STDs are necessary.
B) It is a screening test for syphilis.
C) Abnormal thyroid levels require treatment.
D) If positive, isolation is necessary.
A thyroid profile is important for several reasons.
What role do thyroid levels play in depression?
A) Hypothyroidism can lead to feeling sluggish and depressed.
B) Hyperthyroidism can cause fatigue, weight gain, and depression.
C) The results can be helpful for determining medication therapy for depression.
D) Baseline thyroid levels are required prior to antidepressant medication therapy.
Interventions for Depression
When Anna awakens in the morning, she sits for periods of time at the edge of her bed. She does
not initiate combing her hair, getting dressed, or going to breakfast.
Which nursing intervention is important?
A) Help the client with daily activities.
B) Bring the client's meal to her room.

C) Give two choices of clothes to wear.

D) Respond to the client nonverbally.
Since the client has decreased energy, which intervention is best?
A) Plan a scheduled rest period.
B) Allow for short, frequent naps.
C) Minimize caffeine in the morning.
D) Excuse the client from exercise.
As the nurse initially communicates with Anna, which communication technique is important?
A) Reinforce that she will progressively feel better.
B) Calmly reassure her that everything will be fine.
C) Explain that antidepressants are the best treatment option.
D) Offer options for treatment that will support her needs.
Anna generally declines to participate in the daily, morning community meeting, and refuses to
get out of bed. It takes a great deal of coaxing to get her awakened for meals. She often sits and
stares at her tray.
Treatment Planning
According to the nursing progress notes, Anna demonstrates decreased social interaction, rarely
talks, needs assistance to her room, appears confused, and only slept 30 minutes in the past 24
hours. The daily graphics indicate that she has slept an average of 2 hours in the past week. She
is eating 50% of her meals.
According to this data, what is the priority nursing problem?
A) Altered thought processes.
B) Impaired social interaction.
C) Sleep disturbance.
D) Nutrition imbalance.
Since Anna is eating 50% of her meals, which priority nursing intervention should be included
on the treatment plan?
A) Assess her appetite daily.
B) Include double portions of food.
C) Consult the unit dietician.
D) Weigh weekly and document.

One morning the nurse takes Anna's morning blood pressure, which is 141/108. After reviewing
the progress notes, there were several days when it was elevated. The nurse wants to validate if
she has hypertension.
Which DSM-IV-TR axis would the nurse use to interpret for the presence of hypertension?
A) Axis I.
B) Axis II.
C) Axis III.
D) Axis IV.
Health Risks
The nurse reports the elevated blood pressure to the healthcare provider, and Anna is prescribed
hydrochlorothiazide (Hydro-Chlor) 25 mg daily (a diuretic). The nurse collaborates with the
dietician about Anna's meal plan.
Which recommendation is best to minimize the risk of hypertension?
A) 1200 calorie diet.
B) No added salt to diet.
C) Low cholesterol diet.
D) High protein, low fiber diet.
The nurse knows that there are several risk factors for high blood pressure.
Which risk factor does Anna have?
A) Depression.
B) Decreased energy.
C) Female.
D) African-American.
Suicide Risk
One morning the nurse is doing unit rounds and finds Anna sitting at the edge of her bed with a
sheet around her neck.
What is the first nursing action?
A) Ask, "Are you feeling suicidal?"
B) Stay with Anna.

C) Take the client to the seclusion room.

D) Document the incident in the chart.
The nurse stays with Anna until another staff member arrives and safety precautions are initiated.
The staff must keep Anna in eye sight at all times and document her activity q15 minutes.
When Anna wants to change clothes and get ready for sleep at night, what should the staff do?
A) Keep the door to Anna's room open.
B) Allow only three minutes for Anna to dress.
C) Only allow Anna to change in the bathroom.
D) Allow Anna to change in the unit bathroom.
Anna is placed on constant observation for safety precautions, so the nurse must assign a staff
member to remain with her at all times.
Which staff member is best to assign to Anna?
A) Registered nurse.
B) Unlicensed male counselor.
C) Medication nurse.
D) Unlicensed female counselor.
While Anna is on constant observation, the nurse must assure that safety is maintained in the
milieu. One afternoon the nurse notices that a visitor brings some cans of Anna's favorite soft
What should the nurse do?
A) Pour the soft drink into a paper cup.
B) Stay with Anna when she is drinking it.
C) Explain to the visitor that this is not allowed.
D) Ask Anna to return them to the visitor.
After several days of constant observation, the nurse reassesses the need to maintain safety
What will ensure that the client will be safe?
A) Anna reports feeling less depressed and sleeping better.
B) Staff document that Anna's mood is less depressed.

C) There are no items in Anna's room to cause self-harm.

D) Anna agrees to talk with staff if thoughts of self-harm occur.
ECT Treatment
The lack of progress is reviewed in the treatment team meeting. Anna no longer hears voices, so
the antipsychotic medication is discontinued. A review of the medical record from Anna's former
healthcare provider reveals that she has a past history of depression that was successfully treated
with electroshock therapy. Anna is called into the treatment team meeting to discuss the option of
electroconvulsive treatment (ECT). When asked how shes feeling, Anna looks down, has a
delayed response and states, "Okay." When asked if shes willing to try electroshock treatment
again, she states, "I dont want to go through that again," but consents to treatment. Anna
receives informed consent about the purpose and implications of the treatment and understands
the option to withdraw consent at any time.
The nurse must teach the client about possible adverse effects from the ECT treatments.
Which information should be included in the teaching plan?
A) The severity of side effects depends on the depth of depression.
B) Headache, nausea, and muscle aches may occur after the treatment.
C) The discomfort from ECT is similar to any surgical procedure.
D) ECT is usually given once a week for 6 to 8 weeks.
When the nurse prepares a client for ECT, what should be expected?
A) Preparation is similar to a brief surgical procedure.
B) Clear liquid diet 12 hours before treatment.
C) The client cannot receive any medications.
D) All fluids are withheld four hours before treatment.
Before the first treatment, the nurse thoroughly reviews the information with Anna and again
discusses the treatment. The nurse accompanies Anna to the treatment room and assists her onto
a stretcher. An IV line is inserted and EEG monitoring, which consists of electrodes on the
forehead and mastoid are applied. Blood pressure and pulse are also monitored. Anna must
remove her shoes and socks to allow for placement of a blood pressure cuff on an ankle and
observation of her extremities during the treatment. An electrical stimulus causes a brief seizure
that can be observed in the foot. The seizure generally lasts 30 to 60 seconds.
When Anna awakens from the treatment, the nurse should be prepared to perform which nursing
A) Give Tylenol for headache and muscle aches.
B) Begin twenty-four-hour seizure precautions.

C) Provide stimulation to increase alertness.

D) Take vital signs and assess orientation.
MAO Inhibitors
Anna receives only five ECT treatments because she refused the IV insertion for the remaining
treatments. When asked if she could tell a difference, she answers, "No."
After additional months of therapy with multiple antidepressant medications (both SSRIs and
Tricyclics), the healthcare provider considers treatment with an MAO Inhibitor.
What signs and symptoms should the nurse expect to assess if a client taking an MAO
antidepressant ingests foods containing tyramine?
A) Muscle stiffness and shuffling gait.
B) Diarrhea and increased thirst.
C) Confusion and sore throat.
D) Headache and palpitations.
The nurse plans to give Anna a list of safe and unsafe foods that contain tyramine. Unsafe foods
have high tyramine content, and safe foods have little or no tyramine.
Which food would be considered safe?
A) Most fruits.
B) Most cheeses.
C) Aged meats.
D) Imported beers.
After several days of taking an MAO Inhibitor, Anna refuses to continue taking the medication
and the medication is discontinued.
Which specific nursing consideration is most important?
A) Monitor blood pressure and orthostatic blood pressure.
B) Maintain a low- or tyramine-free diet for 10 to 14 days.
C) Arrange for liver function tests for hepatic dysfunction.
D) Assess the client's mood and affect.
Case Outcome
Anna remains depressed, withdrawn, and isolated. The treatment team wants to pursue
guardianship so that consent for ECT treatment can be obtained. Anna's daughter is unsure and is
consulting an attorney. Meanwhile, the best course of treatment is milieu therapy with

educational and therapeutic groups, individual counseling, and adjunct therapies such as music
and art therapy. Multiple modalities must be used to effectively treat depression and promote
insight for the client.