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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Correct Answer is D
Explanation
D. By offering assistance with getting ready and framing participation in activities as a manageable task, the nurse can help the client overcome feelings of inertia and initiate engagement. It acknowledges the client's current difficulties while providing gentle encouragement to participate in the unit's programs.
A. This response may come across as dismissive of the client's feelings and struggles. It may also increase feelings of guilt or inadequacy in the client, potentially worsening their depressive symptoms.
B. It offers support without pressure and allows the client to take the initiative when they feel comfortable to engage in activities. However, it may not provide enough encouragement or assistance for the client to overcome their depressive symptoms and initiate activity.
C. Encouraging prolonged withdrawal from activities without offering support or motivation to engage may contribute to further isolation and exacerbate depressive symptoms.
Correct Answer is D
Explanation
A. Encouraging client input in the treatment plan is important for promoting client autonomy and engagement in their care. However, while it is a valuable intervention, it may not address the immediate needs or safety concerns of the client with histrionic personality disorder.
B.Clients with HPD may interpret vague or ambiguous communication in exaggerated ways. Concrete language helps prevent misunderstandings and maintains a therapeutic relationship. However, this is not the prority.
C. While assertiveness is valuable, it is not the primary focus at this stage.
D. Managing the clients behavior within the group is the priority intervention for the client who has histrionic personality disorder because these clients display extreme attention seeking behaviors and are often impulsive.
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