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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Correct Answer is B

Explanation

A) Incorrect. While aging can contribute to cognitive changes, it is not the primary factor in the acute onset of delirium.

B) Correct. This statement highlights the acute and rapid onset of behavioral changes, which is characteristic of delirium. Delirium is an acute confessional state characterized by alterations in cognition, attention, and level of consciousness. It often has a sudden onset.

C) Incorrect. Chronic forgetfulness may be indicative of dementia or other cognitive disorders, but it does not support the acute onset seen in delirium.

D) Incorrect. Independence and living alone do not directly relate to the acute onset of delirium.

A. Thyroxine B. Erythropoietin C. Glutamate D. Serotonin

Correct Answer is C

Explanation

A) Incorrect. Thyroxine is a hormone produced by the thyroid gland and is not directly implicated in the etiology of schizophrenia.

B) Incorrect. Erythropoietin is a hormone that stimulates the production of red blood cells and is not directly implicated in the etiology of schizophrenia.

C) Correct. Glutamate, an excitatory neurotransmitter, has been implicated in the development of schizophrenia. Abnormalities in glutamate signaling have been identified in individuals with schizophrenia.

D) Incorrect. While serotonin abnormalities have been associated with mood disorders such as depression, they are not considered a primary factor in the etiology of schizophrenia.

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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

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