A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Refer the client to a mental health care provider for evaluation and treatment.

Determine the presence and degree of suicidal risk.

Identify support groups in the community for long-term treatment.

Assist the client to identify negative effects of chemical dependency.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.

Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.

Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.

Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.

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Correct Answer is B

Explanation

Choice A: Turn on a dance video so the client can burn off excess energy.
This intervention might help the client to channel their energy in a safe and controlled manner. However, it might also reinforce the manic behavior, which could be counterproductive in the long term.

Choice B: Take the client to a calm environment and offer snacks.
This intervention could help to distract the client from their manic behavior and provide them with a calming and grounding experience. Offering snacks could also help to stabilize their energy levels.

Choice C: Offer the client a low-calorie snack in return for stopping the behavior.
This intervention could be seen as a form of behavioral reinforcement. However, it might not be effective if the client is not motivated by food or if they perceive it as a form of manipulation.

Choice D: Observe the client closely for the development of aggressive behavior.
This intervention is crucial for ensuring the safety of the client and others in the unit. If the client's behavior escalates to aggression, the nurse would need to take immediate steps to de-escalate the situation and protect everyone involved.

A. Ask the client if she has a plan to commit suicide. B. Assist the client to her room and allow her to rest before resuming activity. C. Recognize the attempt at manipulation and escort the client back to her activity. D. Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Correct Answer is A

Explanation

Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.

Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.

Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.

Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.

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A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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