A nurse is collecting data from a group of clients who have major depressive disorder.
The nurse should identify that which of the following clients is at the greatest risk for suicide?

A client who has psychomotor retardation.

A client who reports an inability to concentrate.

A client who exhibits an increase in energy.

A client who experiences persistent insomnia.

Answer and Explanation

The Correct Answer is C

The correct answer is: c. A client who exhibits an increase in energy.

Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.

Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.

Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.

Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.

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Correct Answer is A

Explanation

The correct answer is: a. Remove bibs when the infant is going to sleep.

Choice A reason: Removing bibs when an infant is going to sleep is a critical safety measure to prevent suffocation and strangulation risks. Infants should have a sleep environment free of any loose objects that could cover their face and interfere with breathing. The American Academy of Pediatrics recommends keeping the crib clear of items like bibs, pillows, blankets, and toys to reduce the risk of Sudden Infant Death Syndrome (SIDS) and other sleep-related infant deaths.

Choice B reason: Using a highchair for feedings is not recommended for a 3-month-old infant because they typically cannot sit up unsupported at this age. Highchairs are generally used when an infant can sit up well without support and has good head control, usually around 6 months old. Until then, infants should be held or placed in an appropriate reclined feeding position.

Choice C reason: A soft crib mattress is not advisable for infants. A firm mattress is essential to provide a safe sleep surface. Soft mattresses and other soft surfaces increase the risk of SIDS and suffocation because they can create pockets that may cause an infant’s face to sink in and restrict breathing.

Choice D reason: Placing pillows in the crib, even one small pillow, is unsafe for infants. Pillows can pose a suffocation hazard and increase the risk of SIDS. The crib should be kept bare, with only a firm mattress and a fitted sheet, to ensure a safe sleep environment for the infant.

A. Black out the line with a felt-tip pen. B. Leave the space as it is within the entry. C. Draw a horizontal line through the space and sign at the end of the line. D. Place the date at the beginning of the space, followed by double lines.

Correct Answer is C

Explanation

Choice A rationale:

Blacking out the line with a felt-tip pen is not an appropriate action for correcting a blank space in the nurses' notes. It can make the entry look unprofessional and may not be accepted as a proper correction.

Choice B rationale:

Leaving the space as it is within the entry is not the correct action because it does not address the blank space or provide necessary documentation. Blank spaces in documentation should be corrected appropriately.

Choice C rationale:

Drawing a horizontal line through the space and signing at the end of the line is the correct action. This is a standard practice for correcting blank spaces in documentation. It signifies that the space was intentionally left blank and has been reviewed and approved by the nurse.

Choice D rationale:

Placing the date at the beginning of the space, followed by double lines, is not a standard or recommended method for correcting blank spaces in documentation. It can lead to confusion and may not meet documentation standards.

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A nurse is collecting data from a group of clients who have major depressive disorder. The nurse should identify that which of the following clients is at the greatest risk for suicide?

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A nurse is collecting data from a group of clients who have major depressive disorder.
The nurse should identify that which of the following clients is at the greatest risk for suicide?