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 C
Explanation
Choice A rationale:
Epinephrine is not typically used to treat nausea. Nausea is usually managed with antiemetic medications.
Choice B rationale:
Epinephrine is not used to treat hand tremors. Hand tremors may be related to various conditions, and their management would depend on the underlying cause.
Choice C rationale:
The correct manifestation that epinephrine can help treat is "Swelling of the lips." Epinephrine is commonly used to treat severe allergic reactions (anaphylaxis), which can cause swelling of the lips, tongue, and throat. Epinephrine helps to reverse these symptoms by constricting blood vessels and opening the airways.
Choice D rationale:
Epinephrine is not used to treat hyperglycemia. Hyperglycemia is managed with insulin or other antidiabetic medications, not epinephrine.
Correct Answer is D
Explanation
Choice A rationale:
Asking, "What makes you think the staff is following you?" is a confrontational approach and may not be helpful in building rapport or addressing the client's paranoid beliefs. It can come across as dismissive and may exacerbate the client's anxiety.
Choice B rationale:
Telling the client, "The psychiatric staff is not FBI. They are here to help you," is a straightforward response but may not effectively address the client's concerns or build rapport. It does not acknowledge the client's feelings and may not be well-received.
Choice C rationale:
Asking, "Why do you feel the staff is the FBI?" is a more open-ended and therapeutic approach. It encourages the client to express their thoughts and feelings, providing an opportunity for the nurse to better understand the client's perspective.
Choice D rationale:
Saying, "This must be very frightening for you. Let's talk more about it," is the most empathetic and client-centered response. It acknowledges the client's emotions and offers support. It also opens the door for further discussion and therapeutic communication, allowing the nurse to explore the client's fears and concerns in a non-confrontational manner.
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