Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
Restrict visitors to family members only.
Discuss the client's suicide plan.
Limit time allowed to play video games.
Encourage the client to discuss thoughts and feelings about wanting to die.
Reinforce statements regarding a will to live and realistic plans for the future.
Correct Answer : B,D,E
Choice A rationale:
Restricting visitors to family members only may not necessarily be a beneficial intervention and could potentially isolate the client further, which may not be in their best interest.
Choice B rationale:
Discussing the client's suicide plan is essential to assess the level of risk and develop strategies to keep the client safe. It allows the healthcare team to understand the severity of the client's depressive symptoms and potential suicidal ideation.
Choice C rationale:
Limiting the time allowed to play video games may be a consideration in a broader plan of care, but it is not a primary intervention for addressing depression in adolescents. The focus should be on safety, communication, and building a therapeutic relationship.
Choice D rationale:
Encouraging the client to discuss thoughts and feelings about wanting to die is crucial for therapeutic communication and assessment. It provides an opportunity for the client to express their emotions and allows for intervention and support.
Choice E rationale:
Reinforcing statements regarding a will to live and realistic plans for the future is important for building hope and motivation in the client. It can be part of a positive, strengths-based approach to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B"}
Explanation
Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.
Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.
Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis
Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.
Correct Answer is A
Explanation
Choice A Rationale:
Ecchymotic blood accumulations (bruises) are indicative of possible trauma or injury to the scalp. In this case, it suggests that the hair loss is likely due to physical manipulation (such as pulling or arranging the hair to cover bald spots) rather than a medical condition.
Choice B rationale:
This choice suggests that evidence of patches of lost hair would be indicative of non-disease-related hair loss. However, this is not necessarily true. Medical conditions, such as alopecia areata, can also cause patchy hair loss without physical trauma. Therefore, it is not a definitive indicator that hair loss is not disease-related.
Choice C rationale:
Episodic complaints of pruritus (itching) could be associated with various scalp conditions, including those that lead to hair loss. Itching alone does not rule out disease-related hair loss. In fact, some medical conditions can cause both itching and hair loss.
Choice D rationale:
Erythema (redness) of localized lesions may suggest inflammation but does not necessarily indicate non-disease-related hair loss. Medical conditions can also cause localized inflammation and hair loss.
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