A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?
Administer an antidepressant to the client.
Assist the client in completing his ADLs.
Ask the client if he is considering harming himself.
Encourage the client to attend a group therapy session.
The Correct Answer is C
A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.
B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.
C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.
D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is the correct statement. Children with HIV are at increased risk for tuberculosis (TB) infection. Therefore, regular testing for TB is an important part of their healthcare.
B. Doubling medications without specific guidance from the healthcare provider can be dangerous and is not recommended. It's important for the parent to follow the prescribed medication regimen as directed.
C. While zidovudine (AZT) is an important medication for HIV treatment, the statement is not accurate. The risk of transmission does not decrease after only 2 weeks of
treatment. It takes longer for the viral load to decrease significantly.
D. Children with HIV do not necessarily need to repeat their childhood immunizations once they are in remission. However, the timing and need for vaccinations may be
individualized based on the child's specific circumstances and immune status. This statement does not demonstrate a clear understanding of the teaching.
Correct Answer is A
Explanation
A. Hyperpyrexia, or extremely high fever, is a potential complication of acute
acetylsalicylic acid (aspirin) poisoning. It can occur due to the toxic effects of salicylates on the hypothalamus, which regulates body temperature.
B. Polyuria (excessive urination) is not a typical finding associated with acute acetylsalicylic acid poisoning.
C. Jaundice (yellowing of the skin and eyes) is not a typical finding associated with acute acetylsalicylic acid poisoning.
D. Neck vein distention is not a typical finding associated with acute acetylsalicylic acid poisoning. It may be a sign of increased central venous pressure, which is not directly related to salicylate toxicity.
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