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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
"We need to check the client's urine output every hour." Rationale: This statement is not accurate. While monitoring urine output is essential in some postoperative cases, it is not necessary to check it every hour for a client with a urostomy unless there are specific concerns or complications. Monitoring urine output at regular intervals (e.g., every 4-8 hours) is generally sufficient.
Choice B rationale:
"Expect the stoma to appear pale until healing is complete." Rationale: This statement is correct. After urostomy surgery, it is common for the stoma to appear pale or pink initially. As the stoma heals and adapts to its new environment, its color may change. However, informing the client that this change is expected can help alleviate concerns.
Choice C rationale:
"Expect the client's urine to contain clots for the first 24 hours." Rationale: This statement is inaccurate. The presence of clots in urine is not a typical postoperative finding for a client with a urostomy. Clots in the urine could indicate a problem and should be reported to the healthcare provider.
Choice D rationale:
"We will keep the client's fluid intake restricted until he is free of pain." Rationale: This statement is not appropriate for a client with a urostomy. Adequate hydration is essential for clients with urostomies to prevent urinary complications and maintain overall health. Restricting fluid intake is not a standard practice unless there are specific medical reasons to do so.
Correct Answer is C
Explanation
Choice A rationale:
Establish learning outcomes. Establishing learning outcomes is an important step in developing an education program, but it should not be the first step. Before setting learning outcomes, the nurse should assess the participants' needs and abilities, which includes determining their literacy level. Without this information, it is difficult to create meaningful and relevant learning outcomes.
Choice B rationale:
Create handouts for participants. Creating handouts is an essential part of the education program, but it should come after determining the literacy level of participants. Handouts should be tailored to the participants' literacy levels to ensure that they can understand and benefit from the materials provided.
Choice D rationale:
Schedule a time to implement the program. Scheduling a time to implement the program is also an important step, but it should not be the first action taken. Before scheduling, the nurse needs to gather information about the participants' needs and abilities to ensure that the program is appropriately designed and timed for their convenience.
Choice C rationale:
Determine the literacy level of participants. Determining the literacy level of participants should be the first action taken when developing an education program for older adults. This step is crucial because it helps the nurse understand the participants' reading and comprehension abilities. It allows the nurse to tailor the program materials and teaching methods to match the literacy level of the group. Older adults may have varying levels of literacy, and customizing the program to their needs will improve its effectiveness and ensure that participants can fully engage and benefit from the educational content.
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