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.

Answer and Explanation

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.

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Correct Answer is ["E","F","H"]

Explanation

Choice A rationale:
This order is useful to evaluate the client's electrolyte levels, renal function, and acid-base balance, as she has ERSD and missed her dialysis session. She may have hyperkalemia, metabolic acidosis, or uremia, which can affect her cardiac and neurological status.

Choice B rationale:
This order is helpful to assess the client's cardiac structure and function, as she has a history of CAD and HTN and may have developed heart failure or valvular disease.

Choice C rationale:
This order is beneficial to rule out any intra-abdominal causes of the client's nausea and poor appetite, such as infection, obstruction, or bleeding.

Choice D rationale:
This order is necessary to identify any possible source of infection or sepsis, as the client has been ill for 3 days and has a history of diabetes, which can impair her immune system.

Choice E rationale:
This order is important to assess the client's cardiac and pulmonary status, as she has a history of CAD and is presenting with chest discomfort and lightheadedness, which could indicate a cardiac event or pulmonary edema.

Choice F rationale:
This order is essential to monitor the client's heart rate and rhythm, as she has a history of CAD and HTN and is at risk for arrhythmias, ischemia, and infarction.

Choice G rationale:
This order is important to evaluate the client's hematological status, as she has ERSD and may have anemia, leukocytosis, or thrombocytopenia.

Choice H rationale:
This order is crucial to obtain a baseline of the client's cardiac electrical activity and to detect any signs of acute coronary syndrome, such as ST-segment elevation or depression, T wave inversion, or Q waves.

A. Compromised family coping. B. Ineffective sexual patterns. C. Impaired environmental interpretation. D. Disturbed sensory perception.

Correct Answer is D

Explanation

Choice A rationale:
Compromised family coping may be a concern, but it is not the most immediate priority given the client's symptoms of altered reality.

Choice B rationale:
Ineffective sexual patterns is not the primary concern in this scenario, as the client's delusional beliefs and hallucinations take precedence.

Choice C rationale:
Impaired environmental interpretation may be relevant, but it is not the most immediate priority compared to addressing the client's altered perception of reality.

Choice D rationale:
The client's delusional beliefs and hallucinatory experiences suggest disturbed sensory perception, which is a priority nursing problem that requires immediate attention and intervention. These symptoms may indicate a serious mental health condition, such as psychosis, that necessitates psychiatric evaluation and care.

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Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["E","F","H"]

Explanation

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is D

Explanation

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.