A nurse is caring for a client who has major depressive disorder.
The client tells the nurse, "I should be dead.
I have been a failure.”. Which of the following responses should the nurse make?

"You are feeling like a failure.”.

"I see many positive things about you.”.

"You're not the only client who feels this way.”.

"How can you feel that way when you have so much to live for?"

Answer and Explanation

The Correct Answer is A

Choice A rationale

Reflecting the client's feeling back to them, such as "You are feeling like a failure," acknowledges their emotional state without judgment or dismissal. This therapeutic communication technique validates the client's feelings and encourages further exploration of their thoughts and emotions.

Choice B rationale

While intended to be positive, stating "I see many positive things about you" can minimize the client's current feelings and may not address the underlying reasons for their negative self-perception. It can also sound dismissive of their distress.

Choice C rationale

Saying "You're not the only client who feels this way" can minimize the client's individual experience and may make them feel that their feelings are not unique or important. It does not directly address their specific statement of wanting to be dead.

Choice D rationale

Asking "How can you feel that way when you have so much to live for?" invalidates the client's current feelings and can make them feel misunderstood or defensive. It does not address the depth of their despair and suicidal ideation.

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Correct Answer is B

Explanation

Choice A rationale

Liver enzymes (such as ALT and AST) are primarily monitored for medications known to cause liver toxicity. While lithium can have various side effects, it is not typically associated with significant liver damage requiring routine monitoring of liver enzyme levels. Normal ranges for ALT are typically 7 to 55 units per liter (U/L) for men and 5 to 40 U/L for women, and for AST are typically 10 to 40 U/L for men and 9 to 32 U/L for women.

Choice B rationale

Lithium is a mood stabilizer with a narrow therapeutic range, and its levels are closely linked to sodium balance in the body. Hyponatremia (low sodium levels) can increase the risk of lithium toxicity because the kidneys reabsorb lithium in an attempt to compensate for the sodium loss. Therefore, regular monitoring of serum sodium levels is crucial to ensure lithium remains within the therapeutic range (typically 0.6 to 1.2 mEq/L for maintenance) and to prevent toxicity. Normal serum sodium levels are generally 135 to 145 mEq/L.

Choice C rationale

Uric acid levels are primarily monitored in conditions like gout or kidney disease, or as a side effect of certain medications affecting purine metabolism. Lithium does not typically have a significant impact on uric acid levels requiring routine monitoring. Normal uric acid levels are typically 3.5 to 7.2 mg/dL for men and 2.6 to 6.0 mg/dL for women.

Choice D rationale

Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation in the body. While lithium can have various effects, it is not typically associated with significant changes in ESR that would necessitate routine monitoring. Normal ESR values are generally 0 to 15 mm/hr for men and 0 to 20 mm/hr for women. .

A. Ambulate the client three times daily. B. Administer benztropine. C. Increase the temperature in the client's room. D. Implement seizure precautions.

Correct Answer is D

Explanation

Choice A rationale

Encouraging ambulation for a client experiencing severe alcohol withdrawal could be unsafe due to potential instability, tremors, and the risk of falls. Severe withdrawal often involves motor incoordination and impaired balance. The priority is to provide a safe and quiet environment to minimize stimulation and prevent injury.

Choice B rationale

Benztropine is an anticholinergic medication primarily used to treat extrapyramidal symptoms, often associated with antipsychotic medications. It is not a standard treatment for alcohol withdrawal and could potentially worsen some withdrawal symptoms like confusion and tachycardia.

Choice C rationale

Increasing the temperature in the client's room is contraindicated as it can exacerbate diaphoresis, a common symptom of alcohol withdrawal, leading to dehydration and electrolyte imbalances. A cool and well-ventilated environment is generally recommended for these clients.

Choice D rationale

Severe alcohol withdrawal can lead to seizures due to the brain's maladaptation to chronic alcohol exposure and subsequent hyperexcitability upon cessation. Implementing seizure precautions, such as padding the bed rails and having suction equipment readily available, is crucial to ensure the client's safety.

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A nurse is caring for a client who has major depressive disorder.The client tells the nurse, "I should be dead.I have been a failure.”. Which of the following responses should the nurse make?

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A nurse is caring for a client who has major depressive disorder.
The client tells the nurse, "I should be dead.
I have been a failure.”. Which of the following responses should the nurse make?