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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.
It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.
Choice B rationale:
Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.
Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.
It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.
Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.
Choice C rationale:
Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.
It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.
However, it would not typically be the most urgent finding requiring immediate intervention.
Choice D rationale:
Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.
It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.
However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.
Correct Answer is B
Explanation
Choice A rationale:
Asking "Why do you believe you are hearing voices?" is not a suitable response because it challenges the client's reality and can make them feel defensive or invalidated. It's important to validate the client's experience and avoid questioning the reality of their hallucinations.
It can also imply that the client is somehow responsible for their hallucinations, which can be stigmatizing and distressing.
It's more helpful to focus on the content of the hallucinations and how they are affecting the client, rather than on the cause of the hallucinations.
Choice B rationale:
Asking "What are the voices instructing you to do?" is a suitable response because it allows the nurse to assess the content of the hallucinations and the potential for harm.
This information can be used to develop a safety plan and to help the client manage their symptoms.
It also demonstrates to the client that the nurse is taking their concerns seriously and is interested in understanding their experience.
Choice C rationale:
Telling the client "You need to comprehend that there are no voices" is not a suitable response because it is dismissive of the client's experience and can make them feel like they are not being heard or understood.
It's important to remember that hallucinations are very real to the person experiencing them, and telling them that they are not real is not helpful.
It can also damage the therapeutic relationship between the nurse and the client.
Choice D rationale:
Asking "Are the voices familiar to you?" is not a suitable initial response because it is not directly relevant to the client's safety or to the assessment of their symptoms.
While it may be helpful to gather information about the nature of the voices at some point, the priority is to assess the potential for harm and to develop a safety plan.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.