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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Minimizing movement of the limbs is not a recommended action during a seizure. It is important to allow the seizure to run its course while ensuring the safety of the child.

B. Placing the child in a prone position is not recommended during a seizure. The child should be placed in a lateral (side-lying) position to help prevent aspiration and maintain an open airway.

C. This is the correct action. Clearing the area of hard objects helps prevent injury to the child during the seizure. It is important to create a safe environment.

D. Inserting a tongue blade between the teeth is not recommended. This action can cause injury to the child's mouth or teeth. It is a myth that individuals can swallow their tongue during a seizure.

A. Keep staff visits with the child brief. B. Vary daily routines when providing care for the child. C. Place the child in a semiprivate room. D. Keep the television on in the child's room for background noise.

Correct Answer is A

Explanation

A. This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.

B. Children with autism spectrum disorder often thrive on routines and predictability.
Varying daily routines can be distressing and may lead to increased anxiety.

C. Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.

D. Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.

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A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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