An adult client with severe depression was admitted to the psychiatric unit yesterday evening.
Despite having run a marathon a year ago, the client now spends most of the day sitting and watching television, according to the spouse.
What is the most important intervention for the nurse to include in this client’s care plan for today?
Encourage the client to participate in a team sport for one hour.
Assist the client in developing a list of daily affirmations.
Schedule the client for a group session that focuses on self-esteem.
Help the client in identifying goals for the day.
The Correct Answer is D
Choice A rationale
Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.
Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
Reassuring the adolescent that experiencing phantom limb pain can be a normal post-surgical sensation is the correct choice. Phantom limb pain is a common occurrence after amputation and can be very distressing for the patient. The nurse should validate the patient’s experience and provide reassurance. Non-pharmacological interventions such as mirror therapy, visualization, and other cognitive-behavioral strategies can also be helpful.
Choice B rationale
Guiding the patient in moving the non-affected limb to override the sensation being experienced is not the most appropriate intervention. While some therapies for phantom limb pain involve focusing on the remaining limb, this should be done under the guidance of a trained therapist.
Choice C rationale
Telling the patient that the sensations of tingling and pain are not real is not an appropriate intervention. Although the limb is no longer there, the pain that the patient is experiencing is very real. It is important to validate the patient’s experience and provide appropriate interventions.
Choice D rationale
Affirming that a prosthetic with physical therapy will gradually improve the symptoms is not the most appropriate intervention. While using a prosthetic and engaging in physical therapy can help with overall recovery and adaptation after amputation, they do not directly address phantom limb pain. The pain is a result of mixed signals from the brain and nerves, and it requires specific interventions.
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