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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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:
Respiratory depression/arrest is a well-documented risk associated with heroin use. Heroin is an opioid that can significantly depress the central nervous system, leading to slowed or stopped breathing. This can result in hypoxia, a condition where not enough oxygen reaches the brain, which can be fatal.
Choice B reason:
Acute pancreatitis is not typically associated directly with heroin use. While substance use can lead to various health complications, acute pancreatitis is more commonly associated with alcohol abuse rather than opioids like heroin.
Choice C reason:
Nasal septum perforation is a potential risk for individuals who snort heroin. The repeated irritation and damage to the mucosal tissues in the nose can lead to a perforation of the nasal septum, the tissue that separates the nasal passages.
Choice D reason:
Permanent short-term memory loss is not a commonly reported direct effect of heroin use. While chronic use of heroin can lead to cognitive deficits and deterioration of white matter in the brain, which affects decision-making and behavior regulation, it does not specifically cause permanent short-term memory loss.
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