NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW

NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW

Sample Answer for NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW Included After Question

 

NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW
NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW

RESOURCES 

Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.  

WEEKLY RESOURCES 

 

LEARNING RESOURCES 

Required Readings 

Medication Resources 

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments. 

Review the following medications: 

  • amitriptyline 
  • bupropion 
  • citalopram 
  • clomipramine 
  • desipramine 
  • desvenlafaxine 
  • doxepin 
  • duloxetine 
  • escitalopram 
  • fluoxetine 
  • fluvoxamine 
  • imipramine 
  • ketamine 
  • mirtazapine 
  • nortriptyline 
  • paroxetine 
  • selegiline 
  • sertraline 
  • trazodone 
  • venlafaxine 
  • vilazodone 
  • vortioxetine 

Required Media 

Note: The approximate length of this media piece is 59 minutes. 

Note: The approximate length of this media piece is 4 minutes. 

Optional Resources 

iii–v. https://doi.org/10.2989/17280583.2014.938497 

 

 TO PREPARE FOR THIS ASSIGNMENT: 

  • Review this week’s Learning Resources, including the Medication Resources indicated for this week. 
  • Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of vulnerable patient populations requiring antidepressant therapy. 

THE ASSIGNMENT: 5 PAGES 

For this assignment, you will develop a patient medication guide for treatment of depressive disorders in a vulnerable population (your choice for one vulnerable patient population to choose from: children, adolescents, older adults, dementia patients, pregnant women or one not listed of your choice!). Be sure to use language appropriate for your audience (patient, caregiver, parent, etc.). You will include non-copyright images and/or information tables to make your patient medication guide interesting and appealing. Limit your patient medication guide to 5 pages. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 3 scholarly supporting resources outside of your course provided resources. 

In your patient guide, include discussion on the following: 

  • Depressive disorder causes and symptoms 
  • How depression is diagnosed for the vulnerable population of your choice, why is this population considered vulnerable 
  • Medication treatment options including risk vs benefits; side effects; FDA approvals for the vulnerable population of your choice 
  • Medication considerations of medication examples prescribed (see last bullet item) 
  • What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring 
  • Special Considerations (you must be specific, not general and address at least one for EACH category; you must demonstrate critical thinking beyond basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health 
  • Where to follow up in your local community for further information 
  • Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.  

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature. 

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing CenterLinks to an external site. provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632)Links to an external site.. All papers submitted must use this formatting. 

BY DAY 7 

Submit your Assignment.  

SUBMISSION INFORMATION 

Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.  

  1. To submit your completed assignment, save your Assignment as WK4Assgn_LastName_Firstinitial 
  1. Then, click on Start Assignment near the top of the page. 
  1. Next, click on Upload File and select Submit Assignment for review. 

 

Rubric 

NURS_6630_Week4_Assignment_Rubric 

NURS_6630_Week4_Assignment_Rubric 
Criteria  Ratings  Pts 
This criterion is linked to a Learning OutcomeDevelop a patient medication guide for treatment of depressive disorders in a vulnerable population you selected. • Depressive disorder causes and symptoms • How depression is diagnosed for the vulnerable population of your choice 
20 to >17.0 pts 

Excellent Point range: 90–100 

Discussion includes Depressive disorder causes and symptoms; Discussion includes how depression is diagnosed for the chosen vulnerable population. The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient. 

 17 to >15.0 pts 

Good Point range: 80–89 

Discussion is vague regarding Depressive disorder causes and symptoms; Discussion is vague on how depression is diagnosed for the chosen vulnerable population. 

 15 to >13.0 pts 

Fair Point range: 70–79 

Discussion is vague regarding Depressive disorder and missing causes and/or symptoms; Discussion is vague on how depression is diagnosed for the chosen vulnerable population. 

 13 to >0 pts 

Poor Point range: 0–69 

Discussion is inaccurate regarding Depressive disorder and missing causes and/or symptoms; Discussion is missing and/or inaccurate on how depression is diagnosed for the chosen vulnerable population. 

 

 20 pts 
This criterion is linked to a Learning Outcome• Medication treatment options including risk vs benefits; side effects; FDA approvals for the vulnerable population of your choice • Medication considerations of medication examples prescribed • What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring of medications prescribed 
20 to >17.0 pts 

Excellent Point range: 90–100 

Medication treatment options are discussed including risk vs benefits; side effects; FDA approvals for the chosen vulnerable population; Medication considerations of medication examples prescribed; contains discussion of items important to monitor in terms of labs, comorbid medical issues with why important for monitoring. 

 17 to >15.0 pts 

Good Point range: 80–89 

Medication treatment options are briefly discussed and vague regarding risk vs benefits; side effects; FDA approvals for the chosen vulnerable population is vague; vague discussion medication considerations of medication examples prescribed; contains discussion of items important to monitor in terms of labs, comorbid medical issues with why important for monitoring. 

 15 to >13.0 pts 

Fair Point range: 70–79 

Medication treatment options are vague and missing risk vs benefits; side effects; missing discussion of FDA approvals for the chosen vulnerable population; no medication considerations of medication examples prescribed; missing elements of discussing items important to monitor in terms of labs, comorbid medical issues with why important for monitoring. 

 13 to >0 pts 

Poor Point range: 0–69 

Medication treatment options are inaccurate, vague and/or missing including risk vs benefits; side effects; missing or inaccurate discussion on FDA approvals for the chosen vulnerable population; no medication considerations of medication examples prescribed discussed; contains inaccurate, minimal, or no discussion of items important to monitor in terms of labs, comorbid medical issues with why important for monitoring. 

 

 20 pts 
This criterion is linked to a Learning Outcome• Special Considerations (you must be specific, not general and address at least one for EACH category; you must demonstrate critical thinking beyond basics of HIPPA and informed consent!): legal considerations, ethical considerations, cultural considerations, social determinants of health • Where to follow up in your local community for further information 
20 to >17.0 pts 

Excellent Point range: 90–100 

Special Considerations are discussed and specific, not general and address at least one for EACH category demonstrating critical thinking beyond basics of HIPPA and informed consent: legal considerations, ethical considerations, cultural considerations, social determinants of health. Discussion includes directions for where to follow up in local community for further information. 

 17 to >15.0 pts 

Good Point range: 80–89 

Special Considerations are discussed not specific, but general and address at least one for EACH category demonstrating critical thinking beyond basics of HIPPA and informed consent: legal considerations, ethical considerations, cultural considerations, social determinants of health. Discussion includes directions for where to follow up in local community for further information. 

 15 to >13.0 pts 

Fair Point range: 70–79 

Special Considerations are discussed not specific, but general and missing 1-2 of EACH category and does not demonstrate critical thinking beyond basics of HIPPA and informed consent: legal considerations, ethical considerations, cultural considerations, social determinants of health. Discussion directions for where to follow up in local community for further information are vague. 

 13 to >0 pts 

Poor Point range: 0–69 

Special Considerations are discussed not specific, is inaccurate and/or general and missing 3+ or more or does not discuss any of EACH category, inaccurate discussion and/or does not demonstrate critical thinking beyond basics of HIPPA and informed consent: legal considerations, ethical considerations, cultural considerations, social determinants of health. Discussion does not include directions for where to follow up in local community for further information. 

 

 20 pts 
This criterion is linked to a Learning Outcome• The medication guide discusses why the chosen population is considered vulnerable. The medications guide language is appropriate for the intended audience (patient, caregiver, parent, etc). The medication guide is interesting and appealing including use of graphics/tables. 
15 to >13.0 pts 

Excellent Point range: 90–100 

The medication guide discusses why the chosen population is considered vulnerable. The medications guide language is appropriate for the intended audience (patient, caregiver, parent, etc). The medication guide is interesting and appealing including use of graphics/tables. 

 13 to >11.0 pts 

Good Point range: 80–89 

The medication guide is vague in discussion why the chosen population is considered vulnerable. The medications guide language is not consistently appropriate for the intended audience (patient, caregiver, parent, etc). The medication guide is interesting and appealing including use of graphics/tables. 

 11 to >9.0 pts 

Fair Point range: 70–79 

The medication guide does not discuss why the chosen population is considered vulnerable. The medications guide language is not consistently appropriate for the intended audience (patient, caregiver, parent, etc). The medication guide has limited appeal with use of graphics/tables. 

 9 to >0 pts 

Poor Point range: 0–69 

The medication guide does not discuss why the chosen population is considered vulnerable. The medications guide language is not appropriate for the intended audience (patient, caregiver, parent, etc). The medication guide is not interesting and appealing in and/or missing use of graphics/tables. 

 

 15 pts 
This criterion is linked to a Learning OutcomeProvides three examples of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription contains date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. 
15 to >13.0 pts 

Excellent Point range: 90–100 

Provides three examples of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription contains date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. 

 13 to >11.0 pts 

Good Point range: 80–89 

Provides three examples of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription is missing 1-2 elements of the following; date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. 

 11 to >9.0 pts 

Fair Point range: 70–79 

Provides two examples of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription is missing 3 of the following: date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. 

 9 to >0 pts 

Poor Point range: 0–69 

Provides one example of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription is missing 4+ or is inaccurately written for date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. 

 

 15 pts 
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 
5 to >4.0 pts 

Excellent Point range: 90–100 

Paragraphs and sentences follow writing standards for flow, continuity, and clarity. … A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 

 4 to >3.5 pts 

Good Point range: 80–89 

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. … Purpose, introduction, and conclusion of the assignment are stated, yet they are brief and not descriptive. 

 3.5 to >3.0 pts 

Fair Point range: 70–79 

Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. … Purpose, introduction, and conclusion of the assignment is vague or off topic. 

 3 to >0 pts 

Poor Point range: 0–69 

Paragraphs and sentences follow writing standards for flow, continuity, and clarity less than 60% of the time. … No purpose statement, introduction, or conclusion were provided. 

 

 5 pts 
This criterion is linked to a Learning OutcomeWritten Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation; Includes title page and reference page with a minimum of 3 scholarly supporting resources outside of course provided resources. Paper is limited to 5 pages not including title and reference page. 
5 to >4.0 pts 

Excellent Point range: 90–100 

Uses correct grammar, spelling, and punctuation with no errors; Includes title page and reference page with a minimum of 3 scholarly supporting resources outside of course provided resources; Paper is limited to 5 pages not including title and reference page. 

 4 to >3.5 pts 

Good Point range: 80–89 

Contains a few (one or two) grammar, spelling, and punctuation errors; includes the following: title page and reference page. Only contains 2 scholarly supporting resources outside of course provided resources; Paper is 6 pages not including title and reference page. 

 3.5 to >3.0 pts 

Fair Point range: 70–79 

Contains several (three or four) grammar, spelling, and punctuation errors; missing one of the following; title page or reference page; only contains 1 scholaraly supporting resources outside of course provided; Paper is 7 pages not including title and reference page resources. 

 3 to >0 pts 

Poor Point range: 0–69 

Contains many (≥ five) grammar, spelling, and punctuation errors that interfere with the reader’s understanding; missing the following; title page and reference page; contains no scholaraly supporting resources outside of course provided resources; Paper is 8+ pages not including title and reference page. 

 

 5 pts 
Total Points: 100 

 

A Sample Answer For the Assignment: NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW

Title: NURS 6630 ASSESSING AND TREATING VULNERABLE POPULATIONS FOR DEPRESSIVE DISORDERS NEW

Major depression is a mental disorder among most of the American population. Depression affects health, wellbeing and quality of life of the patients and their families. Psychiatric practitioners should be competent in the assessment, diagnosis, treatment, monitoring, and evaluation of depression. They should be able to select evidence-based treatments for vulnerable populations for their recovery and health. Therefore, this essay examines depression among the elderly populations. It focuses on topics such as causes and symptoms, diagnosis, medication treatment options, monitoring and special considerations.  

Causes and Symptoms of Depression 

Depression among the elderly is attributed to several causes. One of the causes is genetics. An elderly patient born to a family with a history of major depression is at a risk of developing the disorder because of the role of genetics. Chronic illnesses also contribute to the development of major depression. For example, the experiences with health issues such as cancer or chronic obstructive pulmonary disease predispose patients to major depression. The use of alcohol and other drugs can also cause depression. Substance use and abuse may produce side effects, which include major depression. Traumatic experiences in life also cause major depression. Patients with histories such as loss of a significant other, job, or undergoing challenges such as a divorce also increases the risk of developing major depression. Imbalances in the neurotransmitters and hormones in the brain also cause major depression. Imbalances in hormones such as acetylcholine and dopamine predispose individuals to major depression (Trenoweth, 2022). Similarly, any disruption in the levels of neurotransmitters such as serotonin and norepinephrine also cause major depression.  

The elderly patients suffering from major depression experience several symptoms. One of them is feeling sad in most of the days, nearly every day. They also raise a significant decline in their interest or pleasure nearly every day. The patients also report weight gain from increased appetite or loss because of decline in appetite. They also experience slowed thought processes, fatigue, and feel worthless or guilty almost every day. The depressed mood makes it hard for them to concentrate or make decisions. In some cases, patients report recurrent suicidal thoughts, attempts, with or without a plan. A comprehensive history taking reveals that the symptoms are not because of a medical condition, medication use or substance abuse (Trenoweth, 2022). In addition, the symptoms affect the normal functioning of the patients in their environments.  

Diagnosis 

The diagnosis of major depression in the elderly patients require a detailed history taking and physical assessment. History taking provides subjective information about the disorder to the practitioner. The psychiatric nurse asks questions that quantify the existence and severity of a health problem. History taking provides insights into potential causes of major depression such as family history of the disease, substance abuse, a history of depression, and the patient experiencing a traumatic event. Physical examination provides subjective information about the disorder. The practitioner relies on methods such as inspection, palpation, percussion, and auscultation. There are also the use of diagnostic and laboratory investigations in physical assessment. The investigations help rule out other potential causes of major depression symptoms in this population (Alshawwa et al., 2019). Nurse practitioners use both subjective and objective assessments to develop accurate diagnoses of their clients’ problems.  

The elderly are considered a vulnerable population when diagnosing and treating mental health problems. First, they are a vulnerable population because of their increased predisposition to multiple comorbidities. Besides major depression, the elderly people also have a high risk of developing chronic conditions such as hypertension, heart failure, and dementia. The elderly patients are also a vulnerable population because of their decline in productivity. Social and occupational productivity decline with aging. The elderly patients have limited involvement in most of the social and occupational roles. As a result, their access to healthcare and other social opportunities is low, making them a vulnerable population. Aging is also associated with decline in physiological functioning. Accordingly, the elderly patients have reduced functioning of the vital organs such as the liver and kidneys. The reduced functioning alters the normal processes such as drug metabolism and excretion (Saedi et al., 2019). The changes places them at a high risk of drug toxicity in disease management, hence, them being a vulnerable population.  

Medication Treatment Options 

Pharmacotherapy is the gold approach to depression treatment in the elderly patients. The treatment phases are three. They include acute, continuation, and maintenance phase. Prescription of drugs for this population should consider their environmental and social contexts. For example, the availability of adequate social support and socialization improves outcomes in the elderly patients suffering from major depression. Most of the elderly patients have pre-existing comorbid conditions such as diabetes and heart failure (Hoel et al., 2021). As a result, the treatment options for major depression should be considered for safety and quality outcomes.  

Antidepressants are the primary drugs of choice in major depression among the elderly. Tricyclic antidepressants such as amitriptyline, desipramine, and nortriptyline are used in some patients. However, patients should be monitored for cardiac and cognition abnormalities. Selective serotonin reuptake inhibitors have a high preference rate for major depression in the elderly patients because of their safety and efficacy levels. Patients should be monitored closely for falls, insomnia, weight gain, and suicidal thoughts and attempts among patients (Li et al., 2021; Miller et al., 2020). The FDA approved antidepressants for use among the elderly patients with major depression include sertraline, citalopram, venlafaxine, mirtazapine, and bupropion.  

Medication Considerations 

Practitioners can consider several medications for treating major depression among the elderly patients. They include sertraline, citalopram, venlafaxine, mirtazapine, and bupropion. The other options for the disorder are venlafaxine, amitriptyline, desipramine, and nortriptyline (Li et al., 2021; Miller et al., 2020). Practitioners should always weigh the risks and benefits associated with the different classes of medications utilized for major depression.  

Monitoring 

Psychiatric mental health nurse practitioners should monitor patients for the side effects associated with the prescribed medications. The use of antidepressants have side effects such as dizziness, constipation, nausea, insomnia, headache, and sexual dysfunction. Patients should be informed that these side effects improve over time. It is important to monitor patients for any cognitive or cardiac abnormalities with the use of tricyclic antidepressants. The risk of falls is also high with the use of antidepressants. Fall risk assessment should be undertaken before prescribing antidepressants to mitigate the risk. Laboratory investigations for serum electrolytes should also be undertaken. Drugs such as selective serotonin reuptake inhibitors increase the risk of hyponatremia due to the development of syndrome of inappropriate antidiuretic hormone secretion. The risk of suicide with antidepressants is also elevated. Follow-up should seek to establish if the patient has developed suicidal thoughts, plans, or attempts (Krause et al., 2019; Perini et al., 2019). Weight changes should also be monitored with the use of antidepressants. Excessive weight gain may predispose the elderly to comorbidities such as diabetes, cardiovascular complications, and fractures.  

Special Consideration and Follow-Up 

Some special considerations influence the choice of treatment for major depression in the elderly patients. As identified initially, most of the elderly patients also suffer from comorbid conditions and decline in physiological processes. The risk of harm during the treatment is high. Psychiatric mental health nurse practitioners must ensure the use of evidence-based treatments that align with the patients’ needs. The focus should be on ensuring quality and safety of the treatment, hence, benevolence and non-maleficence. The treatment of major depression in this population may also demand care coordination. Care coordination requires sharing of information among the different healthcare providers involved in disorder management. As a result, practitioners must ensure data privacy and confidentiality. They should seek informed consent from the patients before sharing any information with the healthcare providers, hence, the protection of autonomy in the care process. Follow-up care is often after four weeks of the first and subsequent treatments (Kupfer, 2005; Pilotto et al., 2020). Patients can benefit from community resources such those by the American Psychological Association and the Centers for Disease Control and Prevention.  

Example of Prescriptions 

Po escitalopram 10 mg od  

Po Sertraline 50 mg od 

Po venlafaxine 37.5 mg bd  

Conclusion 

In conclusion, this paper has explored major depression among elderly populations. The elderly populations are considered vulnerable because of changes in their physiological and physical functioning. Safety should be considered when treating this population due to these changes and existence of multiple comorbidities. Antidepressants are largely used for major depression in the elderly patients. Ethical considerations should inform the selected treatments.  

 

References 

Alshawwa, I. A., Elkahlout, M., El-Mashharawi, H. Q., & Abu-Naser, S. S. (2019). An Expert System for Depression Diagnosis. http://dspace.alazhar.edu.ps/xmlui/handle/123456789/128 

Hoel, R. W., Giddings Connolly, R. M., & Takahashi, P. Y. (2021). Polypharmacy Management in Older Patients. Mayo Clinic Proceedings, 96(1), 242–256. https://doi.org/10.1016/j.mayocp.2020.06.012 

Krause, M., Gutsmiedl, K., Bighelli, I., Schneider-Thoma, J., Chaimani, A., & Leucht, S. (2019). Efficacy and tolerability of pharmacological and non-pharmacological interventions in older patients with major depressive disorder: A systematic review, pairwise and network meta-analysis. European Neuropsychopharmacology, 29(9), 1003–1022. https://doi.org/10.1016/j.euroneuro.2019.07.130 

Kupfer, D. J. (2005). The pharmacological management of depression. Dialogues in Clinical Neuroscience, 7(3), 191–205. https://doi.org/10.31887/DCNS.2005.7.3/dkupfer 

Li, Z., Ruan, M., Chen, J., & Fang, Y. (2021). Major Depressive Disorder: Advances in Neuroscience Research and Translational Applications. Neuroscience Bulletin, 37(6), 863–880. https://doi.org/10.1007/s12264-021-00638-3 

Miller, K. J., Gonçalves-Bradley, D. C., Areerob, P., Hennessy, D., Mesagno, C., & Grace, F. (2020). Comparative effectiveness of three exercise types to treat clinical depression in older adults: A systematic review and network meta-analysis of randomised controlled trials. Ageing Research Reviews, 58, 100999. https://doi.org/10.1016/j.arr.2019.100999 

Perini, G., Cotta Ramusino, M., Sinforiani, E., Bernini, S., Petrachi, R., & Costa, A. (2019). Cognitive impairment in depression: Recent advances and novel treatments. Neuropsychiatric Disease and Treatment, 15, 1249–1258. https://doi.org/10.2147/NDT.S199746 

Pilotto, A., Custodero, C., Maggi, S., Polidori, M. C., Veronese, N., & Ferrucci, L. (2020). A multidimensional approach to frailty in older people. Ageing Research Reviews, 60, 101047. https://doi.org/10.1016/j.arr.2020.101047 

Saedi, A. A., Feehan, J., Phu, S., & Duque, G. (2019). Current and emerging biomarkers of frailty in the elderly. Clinical Interventions in Aging, 14, 389–398. https://doi.org/10.2147/CIA.S168687 

Trenoweth, S. (2022). Understanding Mental Health Practice for Adult Nursing Students. Learning Matters.