Substance Abuse and Abuse Q 12
A client with a diagnosis of major depression, recurrent with psychotic features is admitted to the mental health unit. To create a safe environment for the client, the nurse most importantly devises a plan of care that deals specifically with the client’s:
A. Disturbed thought processes
B. Imbalanced nutrition
C. Self-care deficit
D. Deficient knowledge
Correct Answer: A. Disturbed thought processes
Major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s mental capacity to recognize reality and to communicate and relate to others is impaired, thus interfering with the person’s capacity to deal with the demands of life. Altered thought processes generally indicate a state of increased anxiety in which hallucinations and delusions prevail. Although all of the nursing diagnoses may be appropriate because the client is experiencing psychosis, option A is correct.
Option B: In Imbalanced nutrition, the patient will regain a more normal elimination pattern with aid of foods high in roughage, increased fluid intake, and exercise daily (also with the aid of medications). Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss is noted; minimizes weight loss, constipation, and dehydration.
Option C: In Self-care deficit, the patient will demonstrate progress in the maintenance of adequate hygiene and be appropriately groomed and dressed (shave/makeup, clothes clean and neat). Encourage the use of soap, washcloth, toothbrush, shaving equipment, make-up etc. Give step-by-step reminders such as “Brush the teeth “Clean the outer surfaces of your upper teeth, then your lower teeth. . .” Slowed thinking and difficulty concentrating make organizing simple tasks difficult.
Option D: In Deficient Knowledge, the patient and significant other will verbalize accurate information about at least two of the possible causes of depression, three-four of the signs and symptoms of depression, and use of medications, psychotherapy, and electroconvulsive therapy as treatment.