A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Placing the client on one-on-one observation while monitoring for suicidal ideations

Conducting 15minute checks to ensure safety

Encouraging the client to verbalize feelings related to suicide

Completing a room search to ensure there are no harmful objects available to the client.

Answer and Explanation

The Correct Answer is A

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A) Correct. Amitriptyline, like other tricyclic antidepressants, can cause orthostatic hypotension, which is a drop in blood pressure when changing position from lying to standing.

B) Incorrect. Diarrhea is not a common side effect of amitriptyline.
C) Incorrect. Weight gain is more commonly associated with amitriptyline, not weight loss.
D) Incorrect. Excessive salivation is not a typical side effect of amitriptyline.

Correct Answer is {"dropdown-group-1":"A"}

Explanation

A. Neologisms are new words or expressions created by the individual, often with personal meaning only they understand. "Frobitz" is an example of a neologism.
B. Loose associations involve a lack of logical connection between thoughts and ideas, leading to disjointed or incoherent speech.
C. Delusional thinking involves holding false beliefs that are resistant to reason or contradictory to evidence.
D. Circumstantial speech involves excessive and unnecessary detail before getting to the point of a conversation.

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A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been diagnosed with major depression and placed on amitriptyline. Which is a side effect of amitriptyline?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A"}

Explanation

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