A nurse is caring for an adolescent who has major depressive disorder.
Which of the following actions should the nurse take first?
swer and explanation
Encourage the client to attend a group therapy session
Assist the client in completing his ADLs
Ask the client if he is considering harming himself
The Correct Answer is D
Choice A rationale
Administering an antidepressant to the client is an important part of treatment for major depressive disorder. However, it is not the first action the nurse should take.
Choice B rationale
Encouraging the client to attend a group therapy session can be beneficial for the client’s recovery, but it is not the first action the nurse should take.
Choice C rationale
Assisting the client in completing his ADLs can help the client maintain a sense of normalcy and control, but it is not the first action the nurse should take.
Choice D rationale
Asking the client if he is considering harming himself is the first action the nurse should take. This is because safety is the top priority, and the nurse needs to assess the client’s risk for suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Meperidine is not the first choice for pain management in sickle cell crisis due to its potential to cause seizures and other side effects.
Choice B rationale
Bed rest is recommended during a sickle cell crisis to decrease the body’s demand for oxygen, reduce the workload of the heart, and improve blood flow.
Choice C rationale
Limiting fluid intake is not recommended during a sickle cell crisis. Adequate hydration is important to prevent further sickling of cells and to maintain kidney function.
Choice D rationale
Cold compresses can cause vasoconstriction and may exacerbate the crisis. Warm compresses are usually recommended to increase blood flow and reduce pain.
Correct Answer is D
Explanation
Choice A rationale
Having a vocabulary of 30 words is not a finding that should be reported to the provider for a 24-month-old toddler. By 24 months, most children can say 50 words or more.
Choice B rationale
Sleeping 11 to 12 hours per day is not a finding that should be reported to the provider for a 24-month-old toddler. This is a typical amount of sleep for a child this age.
Choice C rationale
Eating a large amount of food one day then very little the next is not a finding that should be reported to the provider for a 24-month-old toddler. Toddlers often have variable appetites, and it’s normal for them to eat more on some days and less on others.
Choice D rationale
Holding his breath when having a temper tantrum is a finding that should be reported to the provider for a 24-month-old toddler. While breath-holding spells can be a normal part of toddler behavior, they can also be a sign of an underlying medical condition. It’s important for the provider to evaluate this behavior to rule out any potential health concerns.
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