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 D
Explanation
D. Victims of abuse, especially perpetrated by family members, may feel conflicted about reporting the abuse due to feelings of guilt, shame, or fear of repercussions.
A. This implies that the client may believe they cannot report the abuse because they perceive abuse as only valid if there is physical evidence of harm. However, it's important to recognize that abuse can take various forms, including emotional, psychological, financial, and neglectful abuse, which may not always leave physical evidence.
B. While it's true that cases of abuse perpetrated by family members can be complex and challenging to address legally, there are laws and resources available to protect victims of family abuse. Many jurisdictions have laws specifically addressing domestic violence and elder abuse.
C. Reporting abuse to appropriate authorities, such as adult protective services or law enforcement, does not necessarily require hiring legal representation.
Correct Answer is D
Explanation
D. Delusions are false beliefs that are firmly held despite evidence to the contrary. They are not based on reality and are often resistant to rational persuasion or evidence. Delusions can take various forms, such as persecutory (feeling targeted or spied on), grandiose (believing in exaggerated self-importance), or paranoid (feeling threatened or persecuted).
A. Hallucinations involve perceiving sensory experiences that are not present in reality. These sensory experiences can occur in any of the five senses, including seeing, hearing, tasting, smelling, or feeling things that are not actually there.
B. Anhedonia refers to the inability to experience pleasure or interest in activities that are typically enjoyable.
C. Illusions involve misinterpreting real sensory stimuli. Unlike hallucinations, which involve perceiving sensory experiences that are not present, illusions occur when existing sensory stimuli are misinterpreted or distorted.
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