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 A
Explanation
Rationale:
A. Stopping the transfusion is the priority action as it is essential to prevent further potential adverse effects and initiate an investigation of a possible transfusion reaction.
B. Assessing the skin for a rash is important but secondary to stopping the transfusion.
C. Notifying the provider is necessary, but the immediate priority is to stop the transfusion.
D. Covering the client with a blanket does not address the potential severity of a transfusion reaction.
Correct Answer is D
Explanation
Rationale:
A. Reviewing the client's history and reading progress notes are important for understanding the client's situation but are secondary to ensuring the nurse's readiness.
B. Reviewing current provider prescriptions is relevant but does not address the immediate need for self-preparation.
C. Performing self-reflection is essential to ensure that the nurse is emotionally prepared and empathetic, which is crucial when dealing with clients experiencing significant grief.
D. Performing self-reflection is the most critical first step as it ensures the nurse is emotionally prepared and able to provide empathetic and non-judgmental support to the client during a difficult time.