A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

"Are you thinking of harming yourself?"

"Do you really think your family would be better off without you?"

"When did you first start feeling this way?"

"Tell me what is happening right now."

Answer and Explanation

The Correct Answer is A

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

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Correct Answer is ["2"]

Explanation

The nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.

Here's the calculation:

20 mg (desired dose) ÷ 10 mg (strength of each tablet) = 2 tablets

So, the nurse should administer 2 tablets of olanzapine 10 mg orally-disintegrating tablets per dose.

A. Focus attention on meaningful tasks. B. Decrease anxiety to a tolerable level. C. Manipulate and control others' behaviors. D. Limit the amount of time available to interact with others.

Correct Answer is B

Explanation

While the behavior may occupy the client's time and attention, the primary motivation behind OCD-related compulsions is not to engage in meaningful tasks but rather to alleviate anxiety caused by obsessive thoughts.

B. Decrease anxiety to a tolerable level.

Explanation: Individuals with obsessive-compulsive disorder (OCD) often engage in compulsive behaviors, such as cleaning, organizing, or checking, as a way to reduce the anxiety caused by their obsessive thoughts. In this scenario, the client's constant picking up after others is likely a compulsive behavior that serves the purpose of decreasing their anxiety to a tolerable level. The act of tidying up may temporarily alleviate the distress caused by obsessive thoughts related to cleanliness, order, or potential harm.

C. Manipulate and control others' behaviors.

The behavior described does not inherently indicate a desire to manipulate or control others. The behavior is driven by the client's internal anxiety rather than an intention to control external factors.

D. Limit the amount of time available to interact with others.

The behavior is more closely related to managing anxiety than limiting social interactions. OCD-related behaviors are driven by the need to reduce distress, not necessarily to avoid interacting with others.

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A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer olanzapine 20 mg PO daily. Available is olanzapine 10 mg orally disintegrating tablets. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

Correct Answer is B

Explanation

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