A nurse at a primary care clinic is assessing a client for manifestations of depression. Which of the following client statements should the nurse identify as being consistent with depression?
"I can't sit still. I feel like I need to be doing things around the house."
"Lately, I feel like I am more alert than usual and can focus better."
"When I went to my provider, they told me I have high blood pressure."
"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.”
The Correct Answer is D
Rationale:
A. Feeling restless and needing to be active can be more indicative of anxiety or agitation rather than depression.
B. Increased alertness and improved focus are not typical symptoms of depression; rather, depression often involves decreased energy and focus.
C. High blood pressure is not directly related to depressive symptoms.
D. Difficulty sleeping and racing thoughts at night are consistent with depression, particularly when accompanied by poor sleep quality.
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Correct Answer is C
Explanation
Rationale:
A. Narrative therapy is a therapeutic approach that focuses on reshaping personal narratives and is not typically associated with increased risk of self-harm.
B. Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder manage self-harm behaviors and emotional dysregulation, so it would generally reduce, not increase, risk.
C. The period following hospital discharge is often associated with a higher risk of self-harm due to potential lack of support, instability, or feelings of abandonment.
D. While significant life events such as getting married can be stressful, they are not typically associated with the highest risk of self-harm compared to the transitional phase post-discharge.
Correct Answer is B
Explanation
Rationale:
A. A JP drain primarily helps to prevent fluid accumulation, not just limit bleeding.
B. The JP drain is designed to remove fluids and blood from the surgical site, reducing the risk of fluid accumulation and promoting healing.
C. A JP drain does not eliminate the need for wound irrigations if indicated.
D. A JP drain is not used for medication administration; its purpose is drainage.