A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder.
Which of the following interventions should the nurse incorporate into the plan?

Encourage the client to make decisions.

Spend time with the client.

Provide the client with a selection of activities.

Play a game of chess with the client.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While encouraging decision-making can be empowering for some individuals with depression, it may not be appropriate for those with severe depressive disorder.

Individuals with severe depression often experience significant anhedonia (loss of interest in activities), fatigue, and difficulty concentrating, which can make decision-making overwhelming and even worsen their symptoms.

It's important to assess the client's individual level of functioning and decision-making capacity before implementing this intervention.

Choice C rationale:

Providing a selection of activities can be helpful, but it's crucial to tailor the activities to the client's interests and energy level.

Offering too many choices or activities that are too demanding can be counterproductive.

It's essential to collaborate with the client to identify activities that are meaningful and achievable, and to gradually increase the level of activity as tolerated.

Choice D rationale:

Playing a game of chess can be a stimulating and enjoyable activity, but it may not be appropriate for all clients with severe depression.

Chess requires cognitive focus and strategic thinking, which can be challenging for individuals experiencing cognitive impairment or fatigue associated with depression.

It's important to assess the client's cognitive abilities and interests before suggesting this activity.

Rationale for the correct answer, B:

Spending time with the client offers several benefits:

Conveys caring and support: It demonstrates to the client that they are not alone and that someone cares about their wellbeing.

Provides opportunities for therapeutic communication: Spending time together allows for meaningful conversations, which can help the client express their feelings, concerns, and experiences.

Facilitates observation and assessment: The nurse can observe the client's mood, behavior, and interactions, which can inform treatment planning and evaluation.

Promotes engagement and participation: Spending time with the client can encourage them to engage in other therapeutic activities and interventions.

Builds rapport and trust: Developing a strong therapeutic relationship is essential for effective treatment of depression.

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Correct Answer is D

Explanation

Choice A rationale:

Increased salivation is a common side effect of haloperidol, but it is not the most serious adverse effect that the nurse should monitor for. It can be managed with medications such as anticholinergics, and it often subsides with continued use of haloperidol. Choice B rationale:

Serotonin syndrome is a rare but potentially life-threatening condition that can occur when haloperidol is combined with other medications that increase serotonin levels, such as antidepressants. However, it is not a direct adverse effect of haloperidol itself.

Choice C rationale:

Increased menstrual bleeding is not a known side effect of haloperidol.

Choice D rationale:

Tardive dyskinesia is a serious and potentially irreversible movement disorder that can occur as a long-term side effect of haloperidol and other antipsychotic medications. It is characterized by involuntary, repetitive movements of the face, tongue, and limbs.

The risk of tardive dyskinesia increases with the length of time that a person takes haloperidol and with the dose of the medication.

There is no cure for tardive dyskinesia, but the symptoms can sometimes be managed with medications.

It is important for nurses to monitor patients who are taking haloperidol for signs of tardive dyskinesia, so that the medication can be discontinued if necessary.

A. “I know you hear the voices, but I do not.” B. “How often do you hear the voices?” C. “What are the voices telling you?” D. “The voices are part of your illness.”

Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: While acknowledging the client's experience is important, this statement does not immediately address the content of the hallucinations, which could be crucial for assessing the client's safety.

Choice B rationale: Asking how often the client hears the voices is useful information for later, but it is not the immediate priority when first addressing auditory hallucinations.

Choice C rationale: Asking what the voices are telling the client is the priority. This helps the nurse assess if the hallucinations include commands or harmful content, which is essential for determining the client's immediate safety and risk of self-harm or harm to others.

Choice D rationale: Explaining that the voices are part of the client's illness can be useful for long-term understanding, but it does not address the immediate need to assess the content of the hallucinations.

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A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder. Which of the following interventions should the nurse incorporate into the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor the client for which of the following adverse effects?

Correct Answer is D

Explanation

A nurse is caring for a client who is experiencing auditory hallucinations. What should the nurse say first?

Correct Answer is C

Explanation

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A nurse is contributing to the care plan for a newly admitted client suffering from severe depressive disorder.
Which of the following interventions should the nurse incorporate into the plan?