NCLEX RN Case Study Screen 1 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes: 2100: The client is awake, alert, and oriented to person, place, and time. The client reports feelings of hopelessness and expresses thoughts of self-harm. The client has a flat affect and avoids eye contact. Appetite is poor, with the client stating she has not eaten a full meal in three days. The client has not showered or changed clothes in several days. The client reports poor sleep, stating she only sleeps for 23 hours per night. Vital signs: P 88, RR 18, BP 110/70, T 36.5°C (97.7°F), pulse oximetry reading of 98% on room air. Click the findings below that would require immediate follow-up. The client is awake, alert, and oriented to person, place, and time. The client reports feelings of hopelessness and expresses thoughts of self-harm. The client has a flat affect and avoids eye contact. Appetite is poor, with the client stating she has not eaten a full meal in three days. The client has not showered or changed clothes in several days. The client reports poor sleep, stating she only sleeps for 23 hours per night. Vital signs: P 88, RR 18, BP 110/70, T 36.5°C (97.7°F), pulse oximetry reading of 98% on room air.
Case Study Screen 2 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes: 0700: The client reports persistent feelings of sadness and worthlessness. The client remains in bed most of the day and has little interest in activities. The client has been taking sertraline (Zoloft) for the past three weeks but reports no improvement in symptoms. The client expresses frustration with the lack of progress and states, "I don't think anything is going to help me." Vital signs: P 84, RR 18, BP 112/72, T 36.7°C (98.1°F), pulse oximetry reading of 99% on room air. What immediate action should the nurse take regarding the client's lack of response to medication? 1. Increase the dose of sertraline (Zoloft). 2. Reassess the client in one hour. 3. Document the lack of improvement and continue to monitor. 4. Notify the physician immediately.
Answer: 4. Notify the physician immediately.
Case Study Screen 3 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes: 2100: The client reports difficulty sleeping and has been pacing the hallways at night. The client appears anxious and is observed wringing her hands frequently. The client states, "I can't stop worrying about everything." The client denies any recent suicidal thoughts but continues to express feelings of hopelessness. The client has a history of generalized anxiety disorder. Vital signs: P 90, RR 20, BP 115/75, T 36.8°C (98.2°F), pulse oximetry reading of 98% on room air. Which of the following assessment findings would require follow-up? Select all that apply. •
Difficulty sleeping
•
Pacing the hallways at night
•
Anxious appearance
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Wringing hands frequently
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Denial of recent suicidal thoughts
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Answer: •
Difficulty sleeping
•
Pacing the hallways at night
•
Anxious appearance
•
Wringing hands frequently
Case Study Screen 4 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes:
0700: The client reports continued difficulty sleeping despite taking prescribed sleep medication. The client remains anxious and is observed isolating herself from other clients. The client expresses concern about her ability to cope with everyday tasks once discharged. The client is scheduled for a meeting with the psychiatric team to discuss her treatment plan. Vital signs: P 88, RR 18, BP 110/70, T 36.6°C (97.9°F), pulse oximetry reading of 99% on room air. The nurse is discussing the client's treatment plan with the psychiatric team. For each potential nursing intervention, click to specify whether the intervention is appropriate or inappropriate for the care of the client.
Case Study Screen 5 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes:
2100: The client has participated in one-on-one counseling sessions and has attended a group therapy session. The client reports feeling slightly more hopeful but continues to struggle with anxiety and sleep issues. The client has been prescribed lorazepam (Ativan) for anxiety and zolpidem (Ambien) for sleep. The client reports mild improvement in sleep with the new medication. Vital signs: P 85, RR 18, BP 112/70, T 36.7°C (98.1°F), pulse oximetry reading of 99% on room air. For each assessment finding, click to specify if the finding indicates that the client's condition has improved or declined.
Case Study Screen 6 of 6 The nurse is caring for a 35-year-old female client in the psychiatric unit. The client has been admitted for major depressive disorder with suicidal ideation. Nurses' Notes: 0700: The client is preparing for discharge. The client expresses some anxiety about returning home but feels more equipped with coping strategies learned during therapy. The client will continue outpatient therapy and follow up with her primary care provider. The client denies any current suicidal thoughts and reports improved mood and sleep. Vital signs: P 84, RR 18, BP 110/70, T 36.6°C (97.9°F), pulse oximetry reading of 99% on room air.
The nurse is conducting discharge teaching for the client. For each instruction, click to specify if the instruction is essential or non-essential for the client's discharge plan.