A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?
The client assumes an active role in her care planning process.
The client identifies positive qualities about herself.
The client exhibits expected grieving behaviors.
The client makes a contract to avoid self-harm.
The Correct Answer is D
Choice A reason:
While it is beneficial for clients to be involved in their care planning, this is not the immediate priority. Active participation in care planning is a goal that can be pursued once the client's safety and stability are ensured.
Choice B reason:
Identifying positive qualities about oneself is an important step in improving self-esteem and promoting recovery in clients with major depressive disorder. However, this is not the most immediate priority when compared to ensuring the client's safety¹.
Choice C reason:
Exhibiting expected grieving behaviors is a natural and necessary process for healing after the loss of a loved one. However, the priority in the acute phase of care, especially when a client is at risk for self-harm, is to ensure safety.
Choice D reason:
The priority nursing goal for a client with major depressive disorder, especially following a significant loss, is to ensure safety. Making a contract to avoid self-harm is a critical intervention that addresses the risk of suicide, which is heightened in individuals with major depressive disorder and recent significant loss. This contract is a verbal or written agreement between the client and the healthcare provider that the client will not harm themselves and will seek help if they have thoughts of self-harm.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
Choice A Reason:
Elevated blood pressure and heart rate are not typically indicative of sedative-hypnotic drug use. These symptoms are more commonly associated with stimulant use or withdrawal from depressants.
Choice B Reason:
Increased energy and hyperactivity are also not indicative of sedative-hypnotic drug use. These are symptoms that might be observed with stimulant drugs or during withdrawal from depressants.
Choice C Reason:
Excessive drowsiness and sedation are hallmark signs of sedative-hypnotic drug use. Sedative-hypnotics, which include drugs like benzodiazepines and barbiturates, work by depressing the central nervous system, leading to a decrease in brain activity and causing drowsiness and sedation.
Choice D Reason:
While improved sleep quality and duration might be an intended effect of sedative-hypnotic drugs, they are not indicative of acute use or intoxication. These drugs are often prescribed to help with sleep; however, their misuse can lead to excessive sedation beyond normal sleep patterns.
Correct Answer is A
Explanation
Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.
Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.
Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.
Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.
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