A nurse on an acute care for elders (ACE) unit monitors clients ...

[OSWALD]

A nurse on an acute care for elders (ACE) unit monitors clients for functional consequences of depression. Which of the following statements by a client is of highest priority for follow-up?
 
  A) I can't shake this feeling that I've got a cloud hanging over me these days.
  B) I feel like I've got no appetite these days and it takes everything in me just to eat a little meal.
  C) I used to be a powerhouse of energy when I was younger, and now all I can do is sit in a chair.
  D) I think it would be better for everyone if I wasn't here anymore.

Question 2

An older adult is admitted to the hospital with weight loss and cognitive impairment. To assist in the diagnosis of major depressive disorder, for which of the following should the nurse assess? (Select all that apply.)
 
  A) Decreased deep tendon reflexes
  B) Loss of interest or pleasure
  C) Psychomotor agitation
  D) Respiratory difficulty
  E) Sleep disturbances

[Ahnyah]

Answer to Question 1

Ans: D
All of these statements may be indicative of depression, but an allusion to suicide always constitutes the priority for further follow-up.

Answer to Question 2

Ans: B, C, E
Diagnostic criterion for major depression includes depressed mood and/or loss of interest or pleasure along with at least five of the following signs and symptoms: weight loss, appetite change, sleep disturbances, observable, psychomotor agitation or retardation (i.e., slowness), fatigue or loss of energy, feeling worthless or excessively guilty, cognitive impairment, and recurrent thoughts of death or suicide. It does not include deep tendon reflexes or respiratory difficulty.

[OSWALD]

TYSM

[smrtceo]

Excellent