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 A

Explanation

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

Correct Answer is ["1.5"]

Explanation

To calculate the number of clozapine 200 mg tablets needed to administer a total of 300 mg, divide the total dose by the dose per tablet:

300 mg / 200 mg = 1.5 tablets

Since you cannot administer half of a tablet, you would need to administer 2 tablets to achieve a total of 300 mg.

So, the nurse should administer 2 tablets of clozapine 200 mg each to achieve a total dose of 300 mg.

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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 in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is A

Explanation

A nurse is preparing to administer clozapine 300 mg PO daily to a client who has schizophrenia. The amount available is clozapine 200 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.l

Correct Answer is ["1.5"]

Explanation

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