A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Identify support groups in the community for long-term treatment.

Assist the client to identify negative effects of chemical dependency.

Determine the presence and degree of suicidal risk.

Refer client to mental health care provider for evaluation and treatment.

Answer and Explanation

The Correct Answer is C

The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.

choice A and referring the client to a mental health care provider for evaluation and treatment.

choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.

choice B may be necessary but does not address the priority concern of suicidal risk.

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Correct Answer is D

Explanation

A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.

Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.

A. Difficulty using words in context B. Difficulty performing self-grooming activities C. Difficulty in acquiring reading skills D. Difficulty maintaining sustained attention

Correct Answer is D

Explanation

Difficulty maintaining sustained attention is a common manifestation of ADHD, according to the American Psychiatric Association and the CDC. This means that people with ADHD often have trouble focusing on tasks or activities for a long period of time, especially if they are boring or tedious.

The other choices are not manifestations of ADHD, but of other conditions or problems. Here are some reasons why:

Choice A: Difficulty using words in context is not a symptom of ADHD, but of a language disorder or a learning disability that affects communication skills.

Choice B: Difficulty performing self-grooming activities is not a symptom of ADHD, but of a physical disability, a mental health disorder, or a lack of motivation or self-care.

Choice C: Difficulty in acquiring reading skills is not a symptom of ADHD, but of dyslexia, which is a specific learning disability that affects reading and spelling.

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A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Explanation

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