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 B
Explanation
B. Anxiolytics are prescribed to reduce symptoms of anxiety, such as nervousness or restlessness, which can interfere with problem-solving and decision-making abilities. By alleviating anxiety symptoms, the medication can help the client focus more effectively on addressing underlying issues or stressors.
A. While anxiolytics can be effective in managing acute symptoms of anxiety, they are not typically intended for long-term use.
C. Many anxiolytic medications, particularly benzodiazepines, carry a risk of dependence and addiction if used improperly or for an extended period.
D. While anxiolytics can help alleviate symptoms of anxiety, they may not completely eliminate anxiety in all situations.
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.
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