The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Administer thiamine intramuscular (IM)

Assist the client with personal hygiene needs

Place the client on continuous observation

Explain milieu therapy

Answer and Explanation

The Correct Answer is B

A. Administer thiamine intramuscular (IM) Administering thiamine is important, especially in
clients with alcohol abuse, to prevent or treat potential Wernicke Korsakoff syndrome. However, the primary intervention when admitting a client is addressing immediate physical and psychological needs, such as personal hygiene.

B. Assist the client with personal hygiene needs This is the primary intervention upon admission.
It addresses the client's immediate physical and psychological wellbeing and helps establish a therapeutic rapport.

C. Place the client on continuous observation While observation may be necessary for safety, it is not the primary intervention in this scenario. Addressing personal hygiene needs takes precedence.

D. Explain milieu therapy Milieu therapy is an important aspect of a comprehensive treatment plan, but it is not the primary intervention upon admission. Immediate physical care and safety are the initial priorities.

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Correct Answer is C

Explanation

A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.

B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.

C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.

D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.

A. Anhedonia B. Aphasia C. Akathisia D. Agnosia

Correct Answer is D

Explanation

A. Anhedonia is a symptom commonly associated with depression, characterized by a decreased ability to experience pleasure or interest in activities.

B. Aphasia is a language disorder that affects the ability to communicate. It may involve difficulty in speaking, understanding language, reading, or writing. This is not demonstrated in the scenario.

C. Akathisia is a side effect of some antipsychotic medications characterized by a feeling of inner restlessness and the need to move constantly. It is not demonstrated in the scenario.

D. Agnosia is a symptom of dementia characterized by the inability to recognize familiar objects, people, or places, despite the senses being intact. In this scenario, the client's inability to recognize that their glasses are not a form of identification indicates agnosia.

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The nurse is admitting a client with a dual diagnosis of major depressive disorder and alcohol abuse. What is the primary intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with bipolar I disorder is in a manic state, rushing about the unit, and talking regularly with a flight of ideas. What is the most therapeutic intervention?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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