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

Spend time sitting in silence with the client.

Involve the client in a daily exercise program.

Ask the client to describe her depression.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

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Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:
Clonazepam is not typically associated with a significant risk of causing urinary retention or frequent bathroom needs. There's no immediate need for bathroom assistance related to clonazepam use.

Choice B rationale:
Clonazepam is a medication that affects the central nervous system and can influence mental status. Regular assessment helps monitor for any changes or adverse effects.

Choice C rationale:
Clonazepam is administered orally, and it's important to ensure the client's oral health and comfort, especially since dry mouth can be a side effect.

Choice D rationale:
Clonazepam can cause drowsiness and potential changes in blood pressure, which could lead to orthostatic hypotension. Screening for this condition helps ensure the client's safety when changing positions.

Choice E rationale:
Clonazepam does not typically affect calcium levels. Monitoring calcium levels is not a standard nursing intervention when starting clonazepam.

Choice F rationale:
Clonazepam is not an opioid, and it does not require having an opioid agonist at the bedside. This intervention is not relevant to clonazepam use.

A. Concentrate on and ventilate emotions when distressed. B. Shift attention from self to the needs and requests of others. C. Relax and reduce the amount of effort to solve the problem. D. Focus on small achievable tasks, not taxing problems.

Correct Answer is D

Explanation

Choice A Rationale:
While emotional expression and ventilation can be therapeutic, it may not be the most appropriate coping strategy for someone with depression who may already be overwhelmed by negative emotions. Ventilating emotions without a structured approach might not provide the desired relief and can even exacerbate feelings of distress.

Choice B Rationale:
This choice may not be suitable for someone with depression because it could lead to further neglect of their own needs and contribute to feelings of guilt or exhaustion.

Choice C Rationale:
While relaxation techniques can be helpful, reducing the effort to solve problems may not be the most effective strategy for individuals with depression. Avoidance of problems can perpetuate feelings of helplessness and hopelessness.

Choice D Rationale:
For a client with depression who is struggling with handling personal circumstances, focusing on small achievable tasks can be a helpful coping strategy. Breaking down larger problems into manageable steps can reduce feelings of overwhelm and gradually improve the client's sense of accomplishment and self-efficacy.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Correct Answer is D

Explanation

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

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