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
The correct answer is: c. The AP pulls the pinna up and back.
Choice A reason: The AP inserting the probe with a straight, forward motion is not the correct technique for tympanic temperature measurement. The ear canal does not run straight forward into the head; instead, it curves slightly. Inserting the probe straight forward could potentially damage the ear canal or eardrum and would not provide an accurate temperature reading.
Choice B reason: Pointing the probe posteriorly is also incorrect. The tympanic membrane is located at the end of the ear canal, and the probe should be directed towards it. However, the probe should be angled slightly downward and toward the jawline, not straight back, to align with the ear canal and ensure an accurate reading.
Choice C reason: Pulling the pinna up and back is the correct method for adults and children over one year old. This action straightens the ear canal, allowing the thermometer’s sensor to get a clear path to the tympanic membrane, which is necessary for an accurate temperature reading. For infants, the correct method is to pull the earlobe straight back.
Choice D reason: The AP positioning the client facing her does not directly relate to the technique of measuring tympanic temperature. While it may be necessary for the AP to see the client’s ear, it is not an indication of understanding the correct procedure for tympanic temperature measurement.
Correct Answer is A
Explanation
Choice A rationale:
Informed consent is required for invasive procedures that carry significant risks or potential complications. Placement of a central venous catheter is an invasive procedure that involves inserting a catheter into a large vein, often in the neck, chest, or groin. It carries potential risks such as infection, bleeding, and injury to nearby structures. Therefore, informed consent is necessary before performing this procedure.
Choice B rationale:
Insertion of a nasogastric tube is an invasive procedure, but it is generally considered a routine and less risky procedure compared to others. Informed consent is typically not required for nasogastric tube insertion unless there are specific institutional policies or the client lacks decision-making capacity.
Choice C rationale:
Irrigation of a wound with antibiotic solution is a standard nursing procedure, and informed consent is not typically required for wound care unless there are specific circumstances that make it necessary, such as unusual risks or patient-specific considerations.
Choice D rationale:
Administration of an iron injection using Z-track technique is also an invasive procedure, but it is a common and well-established technique for administering intramuscular injections. Informed consent is not routinely required for this procedure unless there are specific institutional policies or the client's condition warrants it.
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