A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?

Ask the client if she has a plan to commit suicide.

Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Recognize the attempt at manipulation and escort the client back to her activity.

Assist the client to her room and allow her to rest before resuming activity.

Answer and Explanation

The Correct Answer is A

Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.

Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.

Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.

Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.

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Correct Answer is B

Explanation

Choice A reason: Encouraging adequate nutrition is important as patients with depression may have decreased appetite.

Choice B reason: Assuring the patient that everything will be fine may minimize their feelings and is not a therapeutic communication technique.

Choice C reason: Maintaining a safe milieu is essential for all patients, especially those with depression who may be at risk for self-harm.

Choice D reason: Using active listening skills is a key component of therapeutic communication and is essential in caring for patients with depression.

A. This means that both sides of your heart are weak and not pumping well. B. This means that the left side of your heart is weak and failing. C. This means that more testing is needed to determine what is wrong. D. This means that the right side of your heart is weak and not pumping effectively.

Correct Answer is D

Explanation

Choice A reason: Cor pulmonale specifically refers to right-sided heart failure. It occurs due to an underlying lung disorder causing pulmonary hypertension (high pressures in the lungs). The right ventricle enlarges and pumps blood less effectively.

Choice B reason:Cor pulmonale does not involve the left side of the heart. It is primarily related to the right ventricle.

Choice C reason: While further testing may be necessary, it does not directly explain cor pulmonale.

Choice D reason:Cor pulmonale results from lung conditions causing pulmonary hypertension.The right ventricle becomes enlarged and less effective due to increased pressure in the pulmonary arteries.

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Naxlex Comprehensive Predictor Exams

The nursing interventions for a patient with major depression would include all the following except:

Correct Answer is B

Explanation

The healthcare provider (HCP) informs the licensed practical nurse/licensed vocational nurse (LPN/LVN) that the patient has cor pulmonale. The patient asks what this means. Which explanation by the nurse is most appropriate?

Correct Answer is D

Explanation

After hospitalization for a myocardial infarction, a patient is placed on a low-sodium diet. In discussing foods allowed on this diet, the nurse would inform the patient that this includes which of the following?

A nurse is assisting in the development of a staff educational inservice about depression. Which of the following factors should the nurse identify as a primary risk factor for depression?

A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?

A nurse is preparing to administer digoxin to a client who has heart failure. Before administering this medication, which of the following actions should the nurse take?

A nurse is caring for a client who has bipolar disorder and states that his latest computer project is "revolutionizing the industry." Which of the following behaviors is the client exhibiting?

A nurse is assisting in the care of a client who has acute onset pulmonary edema and is experiencing dyspnea with low oxygen saturation rates. The nurse should recognize the client is at risk for which of the following acid-base imbalances?

A nurse on the mental health unit is caring for a client who has bipolar disorder and comes to the nurse's station at 0300 demanding to see the provider. Which of the following responses should the nurse make?

Your patient with major depressive disorder isolates herself in her room for the whole day. You find her sitting and staring out the window. What is your best therapeutic response when you walk into her room?