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

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Correct Answer is A

Explanation

A. Walking with the client at a gradually slower pace can provide support and reassurance while helping to regulate the client's activity level. This approach acknowledges the client's distress and offers physical companionship during a challenging time.

B. Instructing the client to sit down and stop pacing may be perceived as confrontational or dismissive of the client's distress. For individuals with generalized anxiety disorder, pacing often serves as a coping mechanism to manage feelings of agitation or restlessness.

C. While ensuring the client's safety is important, forcibly removing them from the corridor may exacerbate feelings of distress or agitation. It is essential to respect the client's autonomy and use interventions that promote de-escalation and emotional support.

D. While allowing the client to pace alone may initially seem like a non-intrusive approach, it may not address the client's underlying emotional distress or provide therapeutic support.

A. "The most common manifestation of postpartum depression is harming the infant." B. "Postpartum depression is more likely to occur in women who have a history of depression." C. "Postpartum depression usually begins 48 hours after childbirth." D. "It's common for clients who have postpartum depression to exhibit psychotic behavior."

Correct Answer is B

Explanation

B. Women with a history of depression, particularly those with a previous episode of postpartum depression, are at increased risk of experiencing postpartum depression after childbirth. Other risk factors include a family history of depression, stressful life events during pregnancy or after childbirth, lack of social support, and hormonal fluctuations.

A. While some women with postpartum depression may experience thoughts of harming themselves or their infant, it is not the most common manifestation.

C. Postpartum depression typically begins within the first few weeks to months after delivery. The onset of symptoms can vary from woman to woman, but they commonly develop within the first three months postpartum.

D. Postpartum psychosis is a psychiatric emergency characterized by symptoms such as hallucinations, delusions, disorganized thinking, and severe mood disturbances.

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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 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?

Correct Answer is A

Explanation

A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?

Correct Answer is B

Explanation

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

A nurse is caring for a client who has schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

A client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

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 home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

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 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?

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?