After establishing a no-harm contract with the client, the nurse should:
continue to maintain close observation.
begin treatment with antidepressants.
begin to assess client risk factors.
decrease observation activity to allow client autonomy.
The Correct Answer is A
A. A no-harm contract is a useful tool. However, it's essential to remember that it's not a guarantee against self-harm. Close observation remains crucial, as suicidal ideation can fluctuate.
B. Antidepressants can be part of the treatment plan but they are not an immediate solution and require careful monitoring. The priority is ensuring the client's safety.
C. This assessment should have already been conducted before establishing the no-harm contract. Ongoing assessment is important, but immediate observation takes precedence.
D. Reducing observation could put the client at risk. Continuous monitoring is necessary to prevent self- harm.
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Related Questions
Correct Answer is D
Explanation
A. This is a primary symptom of depression, not bipolar disorder. While bipolar disorder can include depressive episodes, it also involves periods of elevated mood.
B. This is more characteristic of a condition like anhedonia, often associated with depression, not bipolar disorder.
C. While anxiety can coexist with bipolar disorder, it's not a core symptom of the condition.
D. This is a hallmark symptom of bipolar disorder, specifically the manic or hypomanic phase.
Correct Answer is B
Explanation
A. This is a premature conclusion. While Alzheimer's disease is a possibility, it's essential to rule out other potential causes before making a diagnosis.
B. A comprehensive evaluation can help identify the underlying cause of the symptoms, which could be Alzheimer's disease, other forms of dementia, or even treatable conditions like vitamin deficiencies or thyroid problems.
C. Admission to a nursing home is premature and may not be necessary. The appropriate level of care will depend on the diagnosis and severity of the symptoms.
D. While some memory changes are normal with aging, the described symptoms are more severe than typical age-related forgetfulness. It's important to investigate the cause to determine if there are any underlying medical conditions or cognitive impairments.
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