A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

Communicate to the client that it is acceptable to cry.

Determine the client's stage of grief.

Encourage the client to express feelings openly,

Enable the client to obtain spiritual support.

Answer and Explanation

The Correct Answer is B

A.   While crying may be a normal expression of grief, determining the client’s stage of grief is more important for assessing the client’s emotional needs.
B.   Determining the client’s stage of grief is the first step to understanding the client's emotional state
and providing appropriate support.
C.   Encouraging expression is important, but first, understanding the client’s grief stage will guide the
intervention.
D.   Spiritual support is valuable, but first, understanding the client's emotional response is necessary before offering this type of assistance.

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Correct Answer is A

Explanation

A. Checking the patient's baseline blood pressure helps to determine if the current reading of 98/66 mm Hg is normal for them or if it represents a significant change.
B. This may not be necessary if the blood pressure is normal for the patient. Hypotension is relative, and what is considered low for one person might be normal for another.
C. While this is a good practice, it should be done after determining if there is a significant change from the baseline. The irregular pulse could be due to various factors, including medications, but the first step is to understand the patient's normal range.
D. The patient's pulse is 76 beats/min, which is not bradycardic (bradycardia is defined as a heart rate less than 60 beats/min). Therefore, notifying the doctor of bradycardia is not appropriate in this case.

A. Impaired gait B. Fidgeting behavior C. Muscle contractions of the neck D. Fluctuating vital signs E. Sexual dysfunction

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

Explanation

A. Impaired gait is a classic extrapyramidal symptom, which includes issues like dystonia or bradykinesia.
B. Fidgeting behavior is more related to anxiety or restlessness rather than EPS.
C. Muscle contractions of the neck, known as torticollis, are common signs of EPS caused by antipsychotic medications such as chlorpromazine.
D. Fluctuating vital signs are not directly linked to EPS but may indicate another underlying issue.
E. Sexual dysfunction is a side effect of chlorpromazine but not classified as an EPS.

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A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

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

Explanation

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