A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?
The client will identify positive qualities about herself.
The client will identify ways to achieve a reachable goal for the future.
The client will identify her position in the grief process.
The client will contact a staff member when she feels she might hurt herself.
The Correct Answer is D
D. This goal addresses the immediate safety and well-being of the client. Depression, especially severe depression, can increase the risk of suicidal ideation and behaviors. It is crucial to ensure the client's safety and have measures in place for her to reach out for help if she feels overwhelmed or unsafe.
A. While this is an important goal for improving self-esteem and mood, it may not be the highest priority when the client's safety is at risk.
B. This goal focuses on future planning and motivation, which is important for recovery but may not be as urgent as ensuring immediate safety.
C. Understanding one's grief process is important for emotional healing, but it is not typically as critical as ensuring safety in the immediate term.
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Related Questions
Correct Answer is B
Explanation
B. This is the correct priority action. Serotonin syndrome can be life-threatening if not promptly recognized and treated. The physician needs to be notified immediately so that appropriate actions can be taken to manage the client's symptoms and potentially adjust the medication regimen.
A. Aspirin is not appropriate for treating serotonin syndrome. Monitoring the client's symptoms is important, but this action does not address the potential seriousness of the symptoms described.
C. Delaying notification could lead to worsening of symptoms and potential complications. Given the potential seriousness of serotonin syndrome, waiting until it's convenient is not appropriate.
D. While headache, palpitations, and stiffness could potentially be side effects of antidepressant medication, the combination of these symptoms raises concern for serotonin syndrome, which requires immediate medical attention rather than reassurance alone.
Correct Answer is ["A","B"]
Explanation
A. Denial is a common initial reaction where individuals refuse to accept the reality of their illness. They may minimize symptoms, avoid medical advice, or believe that the diagnosis is incorrect. Denial can serve as a defense mechanism to protect individuals from the shock and emotional distress of a diagnosis.
B. Anger is another stage where individuals may experience frustration, resentment, or hostility towards themselves, others, or the situation. They might feel angry about their diagnosis, the impact it has on their life, or towards healthcare providers and caregivers.
C. Grief is a natural response to loss and can be experienced when individuals face the changes, limitations, or potential outcomes associated with their illness. Grief involves feelings of sadness, despair, and mourning for the life they had before the illness, as well as for potential losses in the future. However, it is not a typical stage of the illness experience.
D. Dependency refers to a stage where individuals may rely on others for physical, emotional, or practical support due to the challenges posed by their illness. This stage can involve seeking assistance with daily activities, relying on healthcare providers for treatment, or leaning on family and friends for emotional support. However, it is not a typical stage of the illness experience.
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