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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bipolar type is not a specific classification; the nurse needs to differentiate between bipolar I and II.
B. Bipolar type I involves manic episodes that last for at least a week or require hospitalization, with possible depressive episodes. The presence of a depressive episode confirms bipolar type I.
C. Bipolar mixed refers to simultaneous symptoms of both mania and depression, which is not described here.
D. Anxiety is unrelated to the symptoms described.
Correct Answer is B
Explanation
A. Hostility and sarcasm are concerning, but they are not as urgent as the risk of injury associated with hyperactivity.
B. Pacing in the hallway during the day and night is indicative of extreme restlessness and may lead to exhaustion or self-harm. The nurse should address this behavior to prevent harm.
C. Giving money away may be problematic, but it is a less immediate risk compared to physical safety.
D. Flight of ideas is a common symptom of mania, but it is less dangerous than pacing and hyperactivity, which can lead to physical harm.
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