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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?

A.

"I can't sit still. I feel like I need to be doing things around the house."

B.

"Lately, I feel like I am more alert than usual and can focus better."

C.

"When I went to my provider, they told me I have high blood pressure."

D.

"I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.”

Answer and Explanation

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 D

Explanation

Rationale:

A. Sharing personal experiences can be supportive, but it may not be the most therapeutic or professional approach in this situation.

B. This question is leading and doesn't encourage an open dialogue. It may also induce guilt or defensiveness in the client.

C. This statement is authoritative and may come across as coercive, which can be counterproductive in encouraging the client to take responsibility for their recovery.

D. Collaborating with the client on a comprehensive plan that includes medication, group support, and counseling is a therapeutic approach that empowers the client to actively participate in their recovery, offering them the best chance of success.

Correct Answer is B

Explanation

Rationale:

A. While inappropriate clothing might indicate a need for assessment of the client’s awareness or physical comfort, it is not as immediate a concern as the client's behavior.

B. The comment to the nurse is concerning as it may indicate disorganized thinking or potential for inappropriate behavior, which requires immediate attention for safety and therapeutic intervention.

C. A heart rate of 102/min is slightly elevated but not the most urgent issue compared to the client's behavior.

D. Elevated blood pressure should be monitored, but the priority is the client’s inappropriate behavior, which may affect safety.

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