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. Hypothermia B. Hypotension C. Tremors D. Respiratory depression

Correct Answer is C

Explanation

Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.

Incorrect:

A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.

B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.

D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.

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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 school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

Correct Answer is D

Explanation

A nurse is assessing a client who is experiencing acute cocaine toxicity. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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