A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Initiating suicide precautions

Administering the Hamilton Depression Scale

Making a contract with the client for eating behavior

Reviewing the client's toxicology laboratory report

Answer and Explanation

The Correct Answer is A

In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.

Incorrect:

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.

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Correct Answer is ["A","B","C","D"]

Explanation

When caring for an adolescent experiencing indications of depression, the nurse should expect the following findings:

A- Irritability: Depression can manifest as increased irritability or anger, especially in adolescents. They may become easily annoyed or frustrated.

B- Insomnia: Sleep disturbances are common in depression. Adolescents may experience difficulty falling asleep, staying asleep, or have restless and disturbed sleep.

C- Chronic pain: Depression can be associated with physical symptoms, including chronic pain. Adolescents may complain of headaches, stomachaches, or other unexplained physical discomfort.

D- Low self-esteem: Depression often involves feelings of worthlessness, guilt, and low self-esteem. Adolescents may have negative thoughts about themselves, feel inadequate, or have a distorted self-perception.

Incorrect:

E- Euphoria, on the other hand, is not a typical finding in depression. It refers to an intense state of happiness or excitement, which is not consistent with the overall mood of depression.

A. Give the client a PRN sleeping medication. B. Explore alternatives to pacing the floor with the client. C. Encourage the client to go back to bed. D. Remain with the client.

Correct Answer is D

Explanation

Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.

A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.

B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.

C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.

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A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A charge nurse is providing teaching to a staff nurse about assisting the provider with electroconvulsive therapy (ECT). Which of the following responses by the staff nurse indicates understanding of the teaching?

A nurse caring for a client who has depression observes the client comes to breakfast freshly bathed wearing clean clothes, and styled hair. Which of the following responses by the nurse is therapeutic?

A nurse is admitting a client who has multiple injuries following a motor vehicle crash. Shortly after admission, the client's partner distraught and blames himself for the accident. Which of the following responses should the nurse make?

A nurse is providing discharge teaching to a client who has bipolar disorder and will be discharged with a prescription for lithium. The nurse should teach the client that which of the following factors puts her at risk for lithium toxicity?

A nurse is caring for an adolescent female who has an eating disorder. The client is 162.6 cm (64 in) tall and weighs 38.56 kg (85 lb). Upon assessment, which of the following manifestations should the nurse expect? (Select all that apply.)

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?

A nurse is caring for a client admitted to a mental health facility who asks, "Can I refuse the electroconvulsive therapy (ECT) treatment so for tomorrow?" Which of the following should be the nurse's response?

A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?