The nurse assessing a client with depression could use which of ...

[arivle123]

The nurse assessing a client with depression could use which of the following to help with the assessment process?
 
  1. Glasgow Coma Scale
   2. Beck Depression Inventory
   3. The client's family members, for answering the assessment questions
   4. More time talking with the client

Question 2

An 82-year-old man is admitted to a medicalsurgical unit for diagnostic confirmation and management of probable delirium.
 
  After assessment by the team caring for the client, which of the following statements by the client's daughter most supports the team diagnosis? 1. Maybe it's just caused by aging. This usually happens by age 82..
   2. The changes in his behavior came on so quickly. I wasn't sure what was happening.
   3. Dad just didn't seem to know what he was doing. He would forget what he had for breakfast..
   4. Dad has always been so independent. He's lived alone for years since my mom died..

[wshriver]

Answer to Question 1

2. Beck Depression Inventory

Rationale:
The Beck Depression Inventory is a series of 21 questions that the client answers in order to self-rate the level of depression. It takes approximately 10 minutes for the client to complete. The nurse can use it to help with the assessment of this client. The Glasgow Coma Scale is not used to assess depression but rather level of responsiveness for neurological conditions. The nurse should not ask family members to answer assessment questions for the client. Assessment of clients with depression is often done in 15 to 20 minute increments since the client usually does not have the energy to talk much longer. For that reason, the nurse should not plan more time with the client to complete the assessment.

Answer to Question 2

2. The changes in his behavior came on so quickly. I wasn't sure what was happening..

Rationale:
Delirium is characterized by a rapid and abrupt onset of symptoms. While delirium is more common in older individuals, aging is not a cause of delirium. Impairments in short-term memory are more indicative of dementia. The fact that he had been independent has no bearing on his current symptoms.

[arivle123]

Excellent

[ghepp]

TYSM