The nurse is caring for a client with a diagnosis of depression. The nurse monitors for signs of constipation and urinary retention, knowing that these problems are likely caused by which situation?

1. Poor dietary choices

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2. Lack of exercise and poor diet

3. Inadequate dietary intake and dehydration

4. Psychomotor retardation and side effects of medication

The nurse is collecting data on a client who is actively hallucinating. Which nursing statement would be therapeutic at this time?

1. “I know you feel ‘they are out to get you,’ but it’s not true.” 2. “I can hear the voice, and she wants you to come to dinner.” 3. “Sometimes people hear things or voices others can’t hear.” 4. “I talked to the voices you’re hearing and they won’t hurt you now.”


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