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","B","C"]

Explanation

A. Brain atrophy is a common physiological change in the brain of individuals with Alzheimer's disease.
B. An overabundance of plaques, specifically amyloid beta, is a characteristic feature of Alzheimer's disease.
C. An overabundance of tangles, specifically tau protein, is also a characteristic feature of Alzheimer's disease.
D. Enlargement of the hippocampus is not typically associated with Alzheimer's disease; rather, it tends to shrink.

E. Enlarged cerebral cortex is not a typical physiological change in Alzheimer's disease; it actually tends to shrink.

A. A depressant B. An opioid C. A stimulant D. An inhalant

Correct Answer is C

Explanation

A. A depressant Depressants typically slow down the central nervous system, leading to
symptoms like sedation, slowed heart rate, and reduced blood pressure. The symptoms described in the question, such as tachycardia, hypertension, restlessness, and agitation, are not
characteristic of depressant use.

B. An opioid Opioids primarily lead to central nervous system depression, resulting in symptoms like respiratory depression, sedation, and decreased heart rate. The symptoms described in the question, such as tachycardia and restlessness, are not typical of opioid use.

C. A stimulant Stimulants, such as amphetamines or cocaine, lead to increased activity in the central nervous system, resulting in symptoms like tachycardia, hypertension, restlessness, and agitation. These symptoms align with the presentation described in the question.

D. An inhalant Inhalants can lead to a variety of effects, including dizziness, confusion, and sometimes increased heart rate. However, they are not typically associated with the specific symptoms of tachycardia, hypertension, restlessness, and agitation described in the question.

View Question and Answer

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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

What are the possible physiological changes in the brain of a client diagnosed with Alzheimer's disease? (Select all that apply)

Correct Answer is ["A","B","C"]

Explanation

A client is admitted with tachycardia, hypertension, restlessness, agitation, and admits substance use. Which substance would be most likely to cause these symptoms?

Correct Answer is C

Explanation

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