A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Instruct family to avoid visiting during mealtimes.

Give the client extra time to communicate needs.

Offer three or four large meals daily.

Discourage rest periods during the daytime.

Answer and Explanation

The Correct Answer is B

Clients with depression may experience cognitive difficulties, such as trouble concentrating or articulating their needs. Giving the client extra time to express themselves and communicate their needs allows them to feel heard and understood. It also helps establish a therapeutic relationship with the client, promoting trust and collaboration in their care.

The other interventions listed may not be appropriate or effective in addressing the client's specific symptoms of depression:

A- Instructing the family to avoid visiting during mealtimes may not be necessary unless there are specific reasons related to the client's preferences or distractions during meals. It's important to involve the family in the client's care and support, including mealtime interactions, unless there are specific concerns or circumstances.

C- Offering three or four large meals daily may not be appropriate for all clients with depression. Some individuals may have a decreased appetite or experience changes in their eating patterns. It is important to assess the client's nutritional needs and preferences and provide a balanced meal plan tailored to their specific situation.

D- Discouraging rest periods during the daytime may not be helpful, as individuals with depression may experience fatigue, lack of energy, and a desire to sleep more. Adequate rest and sleep are important for overall well-being, and it is crucial to support the client in maintaining a regular sleep schedule and addressing any sleep disturbances they may be experiencing.

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Correct Answer is D

Explanation

A. While choice A, “I haven’t gotten my period yet, and all my friends have theirs,” is a valid concern for a 13-year-old, it is generally a normal part of development. Menarche can occur anywhere between ages 9 and 16, so it’s not uncommon for some girls to start later than their peers. However, it is important to address this concern and provide reassurance.

B- "My parents treat me like a baby sometimes." This comment suggests a possible issue with parent-child dynamics, but it does not indicate an immediate health concern. The nurse may explore this further during a counseling session or refer the adolescent to a school counselor if necessary.

C- "There's a big pimple on my face, and I worry that everyone will notice it." While acne can impact an adolescent's self-esteem, it is not a priority issue from a health perspective. The nurse can provide support, discuss basic skincare practices, and offer guidance on managing acne if appropriate.

D. "None of the kids at this school like me, and I don't like them either." This comment indicates potential issues with social relationships, isolation, and possible mental health concerns, which should be prioritized for further evaluation and support. The client might be at risk for depression, an eating disorder or self-harm.

A. "Do not worry about that. Your wife will be fine." B. "I think you should calm down a little before you see your partner." C. "Why do you think the crash is your fault?" D. "Tell me more about your feelings about what happened to your partner."

Correct Answer is D

Explanation

This response acknowledges the client's distress and invites them to share their thoughts and feelings about the situation. It shows empathy and demonstrates active listening, allowing the nurse to gather more information about the client's emotional state and concerns. By giving the client an opportunity to express themselves, the nurse can provide appropriate support and address any guilt or self-blame the client may be experiencing.

Dismissing the client's concerns and redirecting the conversation to their partner's condition (Option A) may invalidate the client's feelings and prevent them from processing their own emotions.

Telling the client to calm down (Option B) may come across as dismissive and insensitive.

Asking the client why they think the crash is their fault (Option C) may put the client on the defensive and hinder open communication. The best approach is to actively listen to the client's concerns and create a supportive environment for them to share their feelings.

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A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Nursing Test Bank

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Correct Answer is D

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Correct Answer is D

Explanation

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