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

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. A structured environment can include regular meal times, consistent routines, and clear expectations. While providing a structured environment is important in the overall management of eating disorders, it may not address the immediate concerns related to the client's severe weight loss and distorted body image.
B. Given the client's significant weight loss and distorted body image, assessing their nutritional status is crucial in understanding the extent of the problem and determining appropriateinterventions.
interventions. However, the client’s symptoms point to a mental health problem.
C. While planning a therapeutic diet is an essential component of the client's long-term treatment plan, it may not be the first priority given the client's current medical and psychological status.

D.Given the client's distorted body image, severe weight loss, and belief that she is fat, requesting a mental health consult is not the first priority. The physiological needs should be addressed first

A. Provide a stimulating environment. B. Schedule daily seclusion times. C. Have consistent unit routines. D. Discourage daytime napping.

Correct Answer is C

Explanation

C. Consistent unit routines are essential for clients in the manic phase of bipolar disorder. Maintaining a structured environment with predictable routines can help stabilize mood, reduce agitation, and provide a sense of security for the client.

A. Mania is characterized by heightened activity, impulsivity, and sometimes agitation. Providing a stimulating environment may exacerbate these symptoms and increase the risk of escalating behaviors or agitation.

B. While it may be necessary to provide a safe and quiet space for the client if they become agitated or overwhelmed, scheduling daily seclusion times implies isolation, which can worsen feelings of loneliness or distress.

D. Excessive daytime napping can disrupt the client's sleep-wake cycle and exacerbate symptoms of mania.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 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?

Correct Answer is B

Explanation

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

Correct Answer is C

Explanation

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

A client experiences panic attacks when confronted with riding in elevators. The therapist is teaching the client ways to relax while incrementally exposing the client to getting on an elevator. This technique is called which of the following?

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?

A nurse is providing teaching to a client who has schizophrenia and is to begin taking haloperidol. Which of the following information should the nurse include in the teaching?

The client with schizophrenia believes the student nurses are there to spy on the clients. The client is suffering from which of the following symptoms?

A client is seeking treatment for a specific phobia. The nurse in the anxiety disorders clinic documents that the client's anxiety is related to exposure to the phobic object. Which is a realistic outcome for anxiety self-control in this situation?