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. Instruct family to avoid visiting during mealtimes. B. Give the client extra time to communicate needs. C. Offer three or four large meals daily. D. Discourage rest periods during the daytime.

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.

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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 planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Correct Answer is B

Explanation

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