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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Clients with depression may experience cognitive difficulties, such as trouble concentrating or articulating their needs. Giving the client extra time to express themselves and communicate their needs allows them to feel heard and understood. It also helps establish a therapeutic relationship with the client, promoting trust and collaboration in their care.
The other interventions listed may not be appropriate or effective in addressing the client's specific symptoms of depression:
A- Instructing the family to avoid visiting during mealtimes may not be necessary unless there are specific reasons related to the client's preferences or distractions during meals. It's important to involve the family in the client's care and support, including mealtime interactions, unless there are specific concerns or circumstances.
C- Offering three or four large meals daily may not be appropriate for all clients with depression. Some individuals may have a decreased appetite or experience changes in their eating patterns. It is important to assess the client's nutritional needs and preferences and provide a balanced meal plan tailored to their specific situation.
D- Discouraging rest periods during the daytime may not be helpful, as individuals with depression may experience fatigue, lack of energy, and a desire to sleep more. Adequate rest and sleep are important for overall well-being, and it is crucial to support the client in maintaining a regular sleep schedule and addressing any sleep disturbances they may be experiencing.
Correct Answer is ["A","B","C","E"]
Explanation
When caring for an adolescent female with an eating disorder, the nurse should expect the following manifestations:
A- Amenorrhea: Amenorrhea refers to the absence of menstruation, which is commonly seen in individuals with eating disorders, particularly in cases of severe weight loss or malnutrition.
B- Altered body image: Individuals with eating disorders often have a distorted perception of their body shape and size. They may see themselves as overweight or have a negative body image, even when they are significantly underweight.
C- Hyperactivity: Some individuals with eating disorders may exhibit excessive physical activity or restlessness. This hyperactivity can be a result of increased energy expenditure, driven by a fear of weight gain or a compulsive need to burn calories.
E- Bradycardia: Bradycardia, or a slow heart rate, is a common finding in individuals with severe malnutrition or very low body weight. It can be a result of the body's adaptive response to conserve energy in a state of limited food intake.
Incorrect:
D- Verbalized desire to gain weight is not typically expected in individuals with eating disorders. They may express a desire to lose weight or have a fear of gaining weight instead.
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