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 B

Explanation

A) Incorrect. Allowing the client to continue at his own pace may not effectively address the issue of circumstantiality and could lead to prolonged, tangential conversations.

B) Correct. Redirecting the conversation can help the client refocus and stay on topic, which can be particularly helpful for someone experiencing circumstantiality.

C) Incorrect. Stopping the client and telling him how his conversation sounds to others may be perceived as confrontational and could potentially be distressing for the client.

D) Incorrect. Reflecting is a useful communication technique, but it may not be the most effective intervention for addressing circumstantiality in this scenario.

A. The client displays agitation. B. The client becomes suddenly cheerful. C. The client experiences psychomotor retardation. D. The client does not attend group therapy.

Correct Answer is B

Explanation

A. Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B. Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C. Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D. Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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