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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Balance when standing with eyes closed is primarily related to the vestibulocochlear nerve (cranial nerve VIII), not the trigeminal nerve.
B. The gag reflex is primarily mediated by the glossopharyngeal nerve (cranial nerve IX), not the trigeminal nerve.
C. Identifying specific scents is related to olfaction, which is primarily mediated by the olfactory nerve (cranial nerve I), not the trigeminal nerve.
D. The trigeminal nerve (cranial nerve V) innervates the muscles of mastication, and symmetrical jaw strength when biting down indicates proper functioning of this nerve.
Correct Answer is A
Explanation
Rationale:
A. An elevated creatinine level may indicate kidney dysfunction, which is a potential adverse effect of gentamicin therapy. It should be reported to the provider for further evaluation.
B. A creatinine level within the normal range is expected.
C. BUN within the normal range is expected.
D. BUN within the normal range is expected.
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