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 C

Explanation

Secondary interventions are aimed at reducing the harm or preventing further complications in individuals who have already engaged in suicidal behavior. In this case, performing life-saving measures after a suicide attempt, such as cardiopulmonary resuscitation (CPR) or administering first aid, falls under the category of secondary intervention.

The other options are examples of primary and tertiary interventions:

A- Recognizing the warning signs of suicide: This is an example of primary intervention, which focuses on preventing suicidal behavior before it occurs by raising awareness, promoting mental health, and identifying risk factors and warning signs.

B- Identifying individuals who are at higher risk for attempting suicide: This is also an example of primary intervention, as it involves assessing and identifying individuals who may be at greater risk for suicidal behavior and implementing preventive measures.

D- Providing support for family and friends following a suicide: This is an example of tertiary intervention, which aims to provide support and care to those who have been affected by a suicide, including family and friends. Tertiary interventions focus on postvention, addressing the aftermath and providing support for survivors.

A. Reinforce postpartum and newborn care discharge teaching. B. Anticipate a prescription by the provider for an antidepressant. C. Assist the family to identify prior use of positive coping skills in family crises. D. Ask the client if she has considered harming

Correct Answer is D

Explanation

In this scenario, a priority action for the nurse is to ask the client if she has considered harming her newborn. The client's symptoms of feeling "down," sadness, lack of energy, and wanting to cry raise concerns about the possibility of postpartum depression, which is a serious mental health condition that can affect new mothers. In some cases, postpartum depression can lead to thoughts of harming oneself or the newborn. Therefore, it is crucial for the nurse to assess the client's risk and ensure the safety of both the client and her baby.

Incorrect:

A- Reinforce postpartum and newborn care discharge teaching: While reinforcing postpartum and newborn care discharge teaching is an important aspect of care, it is not the priority in this situation. The client's symptoms of feeling "down," sadness, lack of energy, and wanting to cry suggest the possibility of postpartum depression. The nurse should prioritize addressing the client's emotional well-being and assessing for potential risks, rather than focusing on routine postpartum and newborn care teaching.

B- Anticipate a prescription by the provider for an antidepressant: While medication may be part of the treatment plan for postpartum depression, it is not the priority action at this stage. The nurse should first assess the client's condition, including the severity of her symptoms and any potential risk of harm to herself or her newborn. Initiating a discussion about medication can come later, in collaboration with the healthcare provider and based on a comprehensive assessment.

C- Assist the family to identify prior use of positive coping skills in family crises: While supporting the client's family and identifying positive coping skills are important, they are not the priority in this scenario. The immediate concern is addressing the client's symptoms and assessing for potential risks associated with postpartum depression. Once the client's immediate safety and emotional needs are addressed, the nurse can involve the family in the care plan and help them identify and utilize positive coping strategies.

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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

Naxlex Comprehensive Predictor Exams

A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?

Correct Answer is C

Explanation

A nurse in a clinic is caring for a client who is 3 weeks postpartum following the birth of a healthy newborn. The client reports feeling "down" and sad, having no energy, and wanting to cry. Which of the following is a priority action by the nurse?

Correct Answer is D

Explanation

A nurse is caring for a client who reports acute, moderate anxiety. Which of the following is the priority nursing action?

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