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","E","F"]
Explanation
Rationale:
A. Defense mechanisms and coping strategies are not the same. Defense mechanisms are unconscious processes used to protect the individual from anxiety and internal conflicts, while coping strategies are conscious efforts to handle stress.
B. Defense mechanisms can be maladaptive and may not always help clients positively deal with stress. They can sometimes hinder adaptive functioning.
C. Defense mechanisms are indeed influenced by neurological and psychological growth. As individuals age, they develop more sophisticated and adaptive mechanisms.
D. Maladaptive defense mechanisms do not improve mental well-being; instead, they can often worsen mental health and impair functioning.
E. Adaptive defense mechanisms, such as sublimation and rationalization, help individuals manage stress more effectively and transform challenges into manageable situations.
F. Adaptive defense mechanisms are characteristic of more mature psychological functioning, reflecting a higher level of emotional resilience and coping.
Correct Answer is B
Explanation
Rationale:
A. While skin color may be an indicator of overall health, it is not the most crucial data point before administering packed RBCs.
B. The hemoglobin level is the most important data to assess before administering packed RBCs, as it provides direct information about the client’s need for the blood transfusion and helps evaluate the effectiveness of the intervention.
C. Fluid intake is important in overall client assessment but is not as immediately relevant as hemoglobin levels when preparing to administer packed RBCs.
D. Temperature should be monitored to check for any signs of infection, but it is not the primary concern when deciding to proceed with a blood transfusion.