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.

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A: I will join a book club in my neighborhood.

Joining a book club in the neighborhood can be a good step towards socializing and overcoming the fear of open or crowded places. However, the success of this step largely depends on the severity of the client's agoraphobia.

Choice B: I plan to sit on a park bench for a few minutes each day.

This is a good practice as it involves gradual exposure to the outside world, which can help in managing agoraphobia. The client can start with a few minutes and then gradually increase the time spent outside.

Choice C: I should avoid entering elevators and other closed spaces.

Avoidance is not a solution for agoraphobia. In fact, avoiding places or situations out of fear can reinforce the phobia. The goal of treatment is to help the client face these situations rather than avoid them.

Choice D: I can try participating in group therapy every week.

Group therapy can be beneficial as it provides a supportive environment where the client can learn from the experiences of others dealing with the same issues. It can also help the client feel less isolated.

A. "Do you really think your family would be better off without you?" B. "Tell me what is happening right now." C. "When did you first start feeling this way?" D. "Are you thinking of harming yourself?"

Correct Answer is D

Explanation

Choice A reason:
Asking the client if they really think their family would be better off without them could potentially validate the client's feelings of worthlessness and is not a priority when immediate safety concerns are present.

Choice B reason:
While it's important to understand the client's current situation, this open-ended question may not directly address the risk of harm the client might pose to themselves. It should follow after ensuring the client's safety.

Choice C reason:
Inquiring about the onset of these feelings is part of a thorough assessment but is not the most immediate concern when a client expresses thoughts that may indicate a risk of self-harm.

Choice D reason:
This direct question addresses the immediate safety concern and is the priority response when a client indicates they may be a danger to themselves. It is essential to assess for suicidal ideation directly to take appropriate steps to ensure the client's safety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

Correct Answer is B

Explanation

A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Correct Answer is D

Explanation

A nurse on an acute care mental health unit is examining the belongings of a client who is being admitted following a suicide attempt. Which of the following belongings should the nurse ask the client's partner to take back home? (Select all that apply)

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

A nurse is caring for a patient with a history of sedative use disorder. Which cue is indicative that a client has used a sedative-hypnotic drug?

A nurse is caring for a client who has been taking Xanax (alprazolam) for anxiety. The nurse anticipates which of the following?

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff on the unit as a follow-up to this incident?

A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

A nurse is caring for a client after an overdose of OxyContin. The nurse anticipates an order for which medication to reverse the effects of the opioids?

A nurse is caring for a client diagnosed with bipolar disorder in an acute manic state. The client is running around the unit asking people to dance with her. After ensuring safety, which of the following interventions should the nurse take?