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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. This statement demonstrates an understanding of exposure therapy, a key component of agoraphobia treatment. Exposure therapy involves gradually facing feared situations or environments to reduce anxiety and desensitize the individual to their triggers.
A. While joining an online book club is a positive social activity, it does not directly address the fear associated with agoraphobia.
B. This statement reflects avoidance behavior, which is common in agoraphobia. However, avoiding
elevators and closed spaces perpetuates the fear and limits the client’s ability to function.
D. Group therapy can be beneficial for clients with agoraphobia. It provides social support, coping strategies, and exposure to others. However, this choice does not directly address the fear of open spaces.
Correct Answer is B
Explanation
B. Systematic desensitization is a behavioral therapy technique used to treat phobias, anxiety disorders, and other fear-related conditions. It involves exposing the individual to the feared stimulus or situation gradually, starting with less anxiety-provoking scenarios and progressing to more challenging ones, while simultaneously teaching relaxation techniques to reduce anxiety.
Systematic desensitization is considered a more gentle and controlled approach compared to flooding and is often preferred for individuals with specific phobias or moderate levels of anxiety.
A. Flooding is a behavioral therapy technique that involves exposing the individual to the feared stimulus or situation at full intensity, without any gradual buildup or relaxation techniques. However, flooding can be highly distressing and overwhelming for some individuals, and it may not be suitable for everyone, especially those with severe anxiety or trauma-related disorders.
C. Cognitive restructuring is a cognitive-behavioral therapy technique used to identify and challenge irrational or negative thoughts and beliefs that contribute to emotional distress or maladaptive behaviors. While cognitive restructuring may be incorporated into treatment for anxiety disorders, it focuses more on addressing cognitive distortions rather than directly exposing the individual to feared stimuli or teaching relaxation techniques.
D. Combination therapy refers to the use of multiple therapeutic approaches or techniques simultaneously or sequentially to address a client's psychological symptoms or concerns. While combination therapy may involve elements of systematic desensitization, cognitive restructuring, and other techniques, it does not represent a specific therapeutic approach or technique on its own.
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