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.
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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Related Questions
Correct Answer is []
Explanation
Alcohol withdrawal syndrome refers to the collection of symptoms that occur when individuals who are dependent on alcohol abruptly reduce or stop their alcohol intake.
Benzodiazepines, such as diazepam or lorazepam, are commonly used to manage symptoms such as anxiety, tremors, and seizures.
Providing a safe environment also ensures that the client does not involve in self-harming activities due to hallucinations.
Alcohol withdrawal syndrome is associated with an increased risk of seizures, particularly within the first 48 hours after cessation of alcohol consumption. Seizures can range from mild to severe and may be life-threatening if not promptly managed.
Chronic alcohol abuse can lead to dehydration and electrolyte imbalances due to increased urinary output, decreased fluid intake, and poor nutrition. Additionally, alcohol withdrawal itself can exacerbate fluid and electrolyte disturbances due to vomiting, diarrhea, diaphoresis, and increased metabolic demand.
Correct Answer is D
Explanation
D. Relaxation techniques, such as deep breathing, progressive muscle relaxation, or mindfulness exercises, can help reduce physiological arousal and anxiety symptoms associated with thoughts of the feared object.
A. Avoidance is a common coping mechanism for individuals with specific phobias. While avoidance may provide temporary relief from anxiety, it does not address the underlying fear and can perpetuate the phobia over time.
B. Facing the feared object without any support or guidance may be overwhelming and could potentially exacerbate anxiety rather than promote self-control.
C. While cognitive restructuring and challenging irrational beliefs about the feared object are important components of cognitive-behavioral therapy for specific phobias, simply stating that the fear is unrealistic and inappropriate may not be sufficient for anxiety self-control.
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