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 C

Explanation

C. Acknowledging the client’s feelings while normalizing them can help reduce the sense of isolation and

provide validation. It’s essential to maintain empathy and avoid dismissing the client’s emotions.

A. While this response acknowledges the client’s feelings, it may come across as confrontational or probing. It’s essential to approach the conversation with empathy and avoid putting the client on the defensive.

B. This response reflects understanding and empathy. However, it does not directly address the client’s

statement about worthlessness.

D. It’s essential to avoid making assumptions about what the client values or finds meaningful. Focusing on empathy and understanding is more effective.

A. The abused person is personally and financially dependent on the abuser. B. The abused person has low self-esteem and defines their success as a person by the ability to make the relationship work. C. The abused person uses alcohol or illegal drugs in the home. D. The abused person believes that they are unable to function without their partner. E. The abused person is afraid that the abuser will kill them if they try to leave.

Correct Answer is ["A","B","D","E"]

Explanation

A. Financial dependence can create barriers to leaving the relationship, especially if the abused person lacks the means to support themselves or their dependents independently.
B. Low self-esteem and a sense of self-worth tied to the relationship can lead individuals to tolerate abuse in hopes of salvaging the relationship or out of fear of being alone.
D. Fear of independence or uncertainty about managing life without the abuser's presence can deter individuals from leaving the relationship.
E. Fear of retaliation or harm from the abuser, including threats of violence or death, can keep individuals trapped in the relationship out of concern for their safety.
C. While substance abuse may contribute to the complexity of an abusive relationship, it is not necessarily a reason why abused persons remain with an abusive partner. Substance abuse can exacerbate existing issues within the relationship but may not be the primary reason for staying.

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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 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?

Correct Answer is C

Explanation

Which are common reasons why abused persons remain with an abusive partner? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

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?

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?

An anxiolytic agent has been prescribed for the client. Which of the following statements by the client would indicate to the nurse that client education about this medication has been effective?

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

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?

A nurse is teaching a client who has a new prescription for disulfiram (Antabuse). Which of the following information should the nurse include in the teaching?

A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)