A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?

Sit with the client and offer simple, direct information.

Explain the unit policies to the client and answer any questions he might have.

Have the client attend group therapy immediately.

Take the client on a tour of the unit and introduce him to all the staff members on duty.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The nurse's approach of sitting with the client and offering simple, direct information is appropriate for a newly admitted client diagnosed with severe depression. This approach allows the nurse to establish a therapeutic rapport and provide the client with essential information in a clear and concise manner. People with severe depression often have difficulty processing complex information, so providing simple and direct information can enhance their understanding and alleviate any feelings of overwhelm.

Choice B rationale:

Explaining the unit policies and answering the client's questions might be overwhelming for someone with severe depression during their initial orientation. People experiencing depression often have difficulties with concentration and retaining information due to cognitive impairment. Presenting them with detailed policies and procedures might increase their anxiety and hinder their ability to absorb the information effectively.

Choice C rationale:

Having the client attend group therapy immediately might not be the best approach for someone with severe depression upon admission. Group therapy could be beneficial later in the treatment process, but initially, the client might not be emotionally ready to engage in group interactions. It's essential to establish a one-on-one therapeutic relationship and provide a stable environment before introducing them to group settings.

Choice D rationale:

Taking the client on a tour of the unit and introducing them to all the staff members on duty might be overwhelming and anxiety-inducing for someone with severe depression. It's crucial to approach the client with sensitivity and respect their emotional state. Introducing them to multiple staff members might increase their social anxiety and make them feel exposed, leading to further distress.

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Correct Answer is C

Explanation

The correct answer is Choice C.

Choice A rationale: Planning a therapeutic diet is essential for the client's recovery. However, it is not the first priority. Understanding the client's nutritional needs and current deficiencies should come before creating a diet plan.

Choice B rationale: Providing a structured environment is important to ensure the client follows the treatment plan and receives the appropriate support. However, it comes after assessing the client's current state and needs.

Choice C rationale: Assessing the client's nutritional status is the first priority because it provides critical information about the client's current health and guides all other aspects of care. Without knowing the client's nutritional status, it is challenging to make informed decisions about her treatment plan.

Choice D rationale: Requesting a mental health consult is important, especially given the client's belief that she is fat and the significant weight loss. However, before addressing her psychological needs, the nurse must understand her physical health status to provide comprehensive care.

A. The client will establish trust with at least one caregiver by day 5. B. The client will participate with peers in a team sport by day 4. C. The client will communicate all needs verbally by discharge. D. The client will perform most self-care tasks independently.

Correct Answer is D

Explanation

Choice A rationale:

Establishing trust with a caregiver in just five days is a challenging and unrealistic expectation for a child diagnosed with autistic spectrum disorder (ASD). Building trust takes time, especially for individuals with ASD who may struggle with social interactions and forming connections.

Choice B rationale:

Participating in a team sport with peers by day 4 might be too ambitious for a child with ASD. Children with ASD often require gradual exposure and support to engage in social activities, and such rapid participation might lead to anxiety and discomfort.

Choice C rationale:

While communication goals are important for children with ASD, expecting them to communicate all needs verbally by discharge might not be realistic. Many children with ASD use alternative forms of communication, such as gestures or assistive devices, which should also be considered as valid modes of expression.

Choice D rationale:

The realistic outcome for a child diagnosed with ASD is that they will perform most self-care tasks independently. ASD often affects social and communication skills, but children can learn and develop the ability to manage self-care tasks with proper support and intervention. This outcome aligns with the developmental trajectory of children with ASD.

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A nurse is planning a unit orientation for a newly admitted client diagnosed with severe depression. Which of the following should be the nurse's approach?

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Naxlex Comprehensive Predictor Exams

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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