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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A reason:
Identifying the client's support systems is an important aspect of the assessment, as support systems can play a crucial role in the client's recovery. However, it is not the highest priority during the initial assessment. Support systems can provide emotional, social, and sometimes financial assistance, which can be beneficial in managing a situational crisis.
Choice B reason:
Identifying the client's coping skills is also important because it helps the nurse understand how the client typically deals with stress and crises. Coping skills are mechanisms that individuals use to manage stressful situations and can include problem-solving, seeking support, and using relaxation techniques. However, this is not the highest priority during the initial assessment.
Choice C reason:
Asking the client to identify the cause of the crisis can provide valuable information about the client's perspective and insight into the situation. Understanding the cause can help in planning appropriate interventions. However, this is not the highest priority during the initial assessment, especially if the client is not in a stable condition to discuss the crisis.
Choice D reason:
Determining if the client has psychotic thinking, is the highest priority. Psychotic thinking can include delusions, hallucinations, and disorganized thoughts, which may indicate a severe mental health condition that requires immediate attention. It is essential to assess for psychotic symptoms to ensure the safety of the client and others, as well as to determine the need for urgent psychiatric intervention.
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