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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Locking the doors and securing windows may prevent an escape attempt, but it does not address immediate risks within the client's environment. It can also make the client feel trapped or punished, which could exacerbate their distress.
Choice B reason:
Removing any objects that could be used for self-harm is a direct intervention that reduces immediate risk. It is a standard safety precaution in managing suicidal clients and helps create a safer environment while further assessments and interventions are planned.
Choice C reason:
Providing plastic eating utensils is a safety measure, but it is not as comprehensive as removing all objects that could be used for self-harm. This action should be part of a broader strategy to ensure safety.
Choice D reason:
Assigning a staff member to stay with the client can provide supervision and prevent an attempt at self-harm. However, it may not be feasible as a long-term solution and does not remove the means for self-harm.
Correct Answer is A
Explanation
Choice A reason:
Respiratory depression/arrest is a well-documented risk associated with heroin use. Heroin is an opioid that can significantly depress the central nervous system, leading to slowed or stopped breathing. This can result in hypoxia, a condition where not enough oxygen reaches the brain, which can be fatal.
Choice B reason:
Acute pancreatitis is not typically associated directly with heroin use. While substance use can lead to various health complications, acute pancreatitis is more commonly associated with alcohol abuse rather than opioids like heroin.
Choice C reason:
Nasal septum perforation is a potential risk for individuals who snort heroin. The repeated irritation and damage to the mucosal tissues in the nose can lead to a perforation of the nasal septum, the tissue that separates the nasal passages.
Choice D reason:
Permanent short-term memory loss is not a commonly reported direct effect of heroin use. While chronic use of heroin can lead to cognitive deficits and deterioration of white matter in the brain, which affects decision-making and behavior regulation, it does not specifically cause permanent short-term memory loss.
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