When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Involve client in daily exercise program.

Ask the client to describe her depression.

Spend time sitting in silence with client.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is C

A.   Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B.   Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C.   Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D.   Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

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Correct Answer is A

Explanation

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

A. Blood pressure. B. Urinary output. C. Respiratory rate. D. Temperature.

Correct Answer is A

Explanation

Rationale:
A. MAO inhibitors such as phenelzine can cause significant fluctuations in blood pressure, including hypertensive crisis when combined with certain foods or medications. Therefore, monitoring blood pressure is crucial to detect and prevent hypertensive emergencies.
B. While monitoring urinary output is important for overall assessment, it is not specifically associated with the use of MAO inhibitors like phenelzine.
C. Respiratory rate is not typically affected by MAO inhibitors like phenelzine and may not be the most relevant assessment finding in this scenario.
D. Temperature monitoring is important for general assessment but is not specifically associated with the use of MAO inhibitors like phenelzine.

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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Correct Answer is A

Explanation

In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?

Correct Answer is A

Explanation

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

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