What is the priority finding to report to other disciplines for a client who has major depressive disorder?

Significant weight loss

Markedly neglected hygiene

Psychomotor retardation

Poor problem-solving skills

Answer and Explanation

The Correct Answer is A

Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.

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Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

A. Impaired memory B. Inappropriate speech patterns C. Command hallucinations D. Rapid mood swings

Correct Answer is C

Explanation

Command hallucinations are auditory hallucinations that instruct the client to perform an action, such as harming oneself or others. This is a medical emergency that requires immediate intervention by the nurse to ensure safety and prevent harm.

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What is the priority finding to report to other disciplines for a client who has major depressive disorder?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse manager is observing a newly licensed nurse preparing to administer an IM medication to a client who is manic and refuses the medication. Which of the following actions should the nurse manager take first?

Correct Answer is B

Explanation

A nurse is assessing a client who has delirium. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is C

Explanation

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

A nurse in an alcohol rehabilitation facility is creating a discharge plan for a client who has alcohol use disorder. Which of the following recommendations should the nurse include in the plan?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?

What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

A home health nurse is caring for a client who is in the continuation phase of major depressive disorder. The client states, "I feel unmotivated and don't feel like leaving my home." Which of the following recommendations should the nurse make to address the client's social isolation?

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline. The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?