A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first?
Ask the client if he is considering harming himself.
Encourage the client to attend a group therapy session.
Administer an antidepressant to the client.
Assist the client in completing his ADLs.
The Correct Answer is A
Rationale:
A. Assessing the risk of self-harm or suicide is the top priority when caring for a patient with major depressive disorder. It allows the nurse to intervene immediately if there's a risk of harm.
B. While group therapy can be beneficial for individuals with depression, it's not the first priority when assessing for safety concerns.
C. Administering antidepressants may be part of the treatment plan, but it's essential to assess the immediate risk of self-harm before proceeding with medication administration.
D. Assisting with activities of daily living is important, but it's not the first action to take when assessing for safety in a patient with major depressive disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
Correct Answer is A
Explanation
Rationale:
A. A child with cystic fibrosis needs a high-calorie diet to meet their nutritional needs and prevent malnutrition.
B. Sweat chloride testing is used to diagnose cystic fibrosis, not to monitor its progression.
C. Chewing pancrelipase medication before eating is incorrect. Pancrelipase should be swallowed whole with meals to aid in digestion.
D. Administering dornase alfa every 4 hours for wheezing is not appropriate. Dornase alfa is typically used for cystic fibrosis to help thin mucus and improve lung function, but it is not indicated for wheezing, and the dosing frequency provided is incorrect.
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