HESI Case Study Depression
Patient Assessment and Initial Interaction
1. Priority Nursing Assessment: - Determine how long the client has been hearing the voice and what it is saying. - Understanding the nature of the hallucinations is vital to assess the severity of the situation and
determi...
- Determine how long the client has been hearing the voice and what it is saying.
- Understanding the nature of the hallucinations is vital to assess the severity of the situation and
determine any risk of self-harm.
Behavioral Assessments
2. Behavior Inconsistent with Depression:
- Hearing a man's voice.
- Auditory hallucinations are generally more indicative of a psychotic disorder and may not be typical
for depression alone. However, they may occur in psychotic depression.
Consent and Involuntary Treatment
3. Justifying Short-term Involuntary Treatment:
- Unable to meet basic self-care needs.
- Involuntary treatment is justified when clients cannot care for themselves adequately and may be a
danger to themselves or others.
- States she has a plan to harm herself.
- This also justifies short-term involuntary care to protect the patient.
Medication Management
4. Classification of Antidepressant:
- Fluoxetine (Prozac) is classified as a Selective Serotonin Reuptake Inhibitor (SSRI).
- SSRIs target serotonin levels in the brain, which can improve mood.
5. Major Action of SSRIs:
- Increase availability of serotonin.
, - SSRIs work by inhibiting the reuptake of serotonin, ensuring that more serotonin is available in the
synapse.
6. Rationale for SSRI Preference Over Tricyclics:
- Tricyclics are more lethal in an overdose.
- SSRIs have a safer side effect profile and are less likely to cause fatal overdose compared to tricyclic
antidepressants.
7. Expected Therapeutic Effectiveness Timeline:
- Generally within 2 to 4 weeks.
- While SSRIs can take time to show effect due to the need for neurochemical adjustments, this
timeframe is typical for many patients.
Side Effects to Monitor
8. Common Side Effects of SSRIs:
- Gastrointestinal disturbances.
- Clients taking SSRIs commonly report side effects like nausea, diarrhea, and other gastrointestinal
issues, especially when starting the medication.
(GI disturbances such as nausea and diarrhea, as well as genitourinary side effects such as sexual
dysfunction, are common with SSRIs. SSRIs do not have significant anticholinergic, cardiovascular, or
sedative side effects)
9. the client also begins an atypical antipsychotic, risperidone (Risperdal), because she reports hearing a
"scary voice" upon admission. although the client remains very withdrawn and noncommunicative, the
nurse must explain the purpose of Risperdal. Which explanation is best? ✔️"This medication will help
you think more clearly."
(antipsychotic medications target symptoms related to disorders of things such as psychosis and
behaviors associated with agitation and disorganization or speech and behavior)
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