An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Monitor food intake and eliminate potential sources of tyramine.

Assess for weight loss and difficulty sleeping.

Monitor the client for migraines.

Implement suicide precautions.

Answer and Explanation

The Correct Answer is D

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

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Correct Answer is A

Explanation

A. Fluoxetine and other selective serotonin reuptake inhibitors (SSRIs) typically require several weeks of treatment before the full therapeutic effects are realized. Therefore, it's important for the nurse to reassure the client that it may take some time for the medication to alleviate depressive symptoms fully.

B. While lack of improvement in depressive symptoms after two weeks of fluoxetine treatment may be concerning, it's generally recommended to wait at least 4 to 6 weeks before considering changing or adjusting the antidepressant regimen.

C. Monoamine oxidase inhibitors (MAOIs) are another class of antidepressant medications that may be considered for treatment-resistant depression. However, MAOIs have significant dietary and medication restrictions and carry the risk of potentially serious drug interactions.

D. While sleep disturbances are common in major depressive disorder, recommending a sleep study as the first intervention for a client who is not responding to antidepressant treatment after only two weeks may not be the most appropriate action.

A. "Why do you feel you are worthless?" B. "You've been feeling that your life has no meaning." C. "It's not unusual for depressed people to feel that way." D. "You have a great deal to live for."

Correct Answer is C

Explanation

C. Acknowledging the client’s feelings while normalizing them can help reduce the sense of isolation and

provide validation. It’s essential to maintain empathy and avoid dismissing the client’s emotions.

A. While this response acknowledges the client’s feelings, it may come across as confrontational or probing. It’s essential to approach the conversation with empathy and avoid putting the client on the defensive.

B. This response reflects understanding and empathy. However, it does not directly address the client’s

statement about worthlessness.

D. It’s essential to avoid making assumptions about what the client values or finds meaningful. Focusing on empathy and understanding is more effective.

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An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and was prescribed fluoxetine 2 weeks ago. The client reports having an improved appetite, but still feels very depressed and is still having trouble sleeping. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is teaching a client who has a new prescription for disulfiram (Antabuse). Which of the following information should the nurse include in the teaching?

An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client's head down, and he is wringing his hands. Which of the following actions should the nurse take?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting. and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A coherent older client has been financially and emotionally abused by their adult children for the past several years but has not reported the abuse to anyone. Which is the most likely reason that the client has not reported the abuse?

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?