A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the client suddenly seems cheerful and relaxed, and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?

Ask the client why her behavior has changed.

Reward the client for her change in behavior.

Monitor the client's whereabouts at all times.

Encourage the family to take the client out of the facility for short periods of time.

Answer and Explanation

The Correct Answer is C

A. While it is important to understand changes in behavior, the sudden shift from depression to a cheerful state could be indicative of a potential risk, such as a plan to self-harm, particularly if the client is showing improved mood quickly.

B.It is not appropriate to reward a change in behavior without understanding the underlying reasons for the change. The sudden improvement in mood could be a sign of a potential risk, such as suicidal ideation or a temporary lift in mood before a possible crisis.

C. This is a crucial intervention. A sudden change in mood can sometimes be associated with an increased risk of self-harm or suicidal ideation, particularly if the client’s mood improves significantly before a more stable improvement in their depressive symptoms. Continuous monitoring helps ensure the client’s safety.

D.This could be premature and potentially unsafe, given the sudden and significant change in the client's condition. It is more important to ensure that the client’s mood change is not indicative of an underlying risk before allowing unsupervised activities.

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Correct Answer is D

No explanation

A. Giving the client choices of activities. B. Playing a game of chess with the client. C. Encouraging decision-making. D. Spending time sitting with the client.

Correct Answer is D

Explanation

a. Giving the client choices of activities: While providing choices can be empowering for clients, it might be overwhelming for someone with severe depression, who may struggle with decision-making and motivation.

b. Playing a game of chess with the client: This could be too mentally demanding and may not be appropriate for a client with severe depression, who may have difficulty concentrating or engaging in complex activities.

c. Encouraging decision-making: Encouraging decision-making is important in general, but clients with severe depression may find it difficult and stressful to make decisions. This approach should be used cautiously and based on the client's readiness.

d. Spending time sitting with the client: This is correct and therapeutic. Spending time with the client without the pressure to engage in conversation or activities can help the client feel supported and understood. It fosters trust and shows that the nurse is there to provide support, which is especially important for someone experiencing severe depression.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

Correct Answer is D

A nurse is caring for a client who is hospitalized for the treatment of severe depression. Which of the following nursing approaches is therapeutic to include in the client's plan of care?

Correct Answer is D

Explanation

A nurse on an inpatient mental health unit is caring for a client who has major depressive disorder and malnutrition. Which of the following actions should the nurse take to improve the client's nutritional status?

A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.).

A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?

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?

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?