A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Placing the client on one-on-one observation while monitoring for suicidal ideations

Conducting 15minute checks to ensure safety

Encouraging the client to verbalize feelings related to suicide

Completing a room search to ensure there are no harmful objects available to the client.

Answer and Explanation

The Correct Answer is A

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

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Correct Answer is A

Explanation

A) Correct. Ecstasy, also known as MDMA (3,4methylenedioxymethamphetamine), belongs to the hallucinogen class of drugs. It produces altered perceptions and sensations.

B) Incorrect. Hypnotics are drugs that promote sleep.
C) Incorrect. Opioids are a class of drugs that include substances like heroin and prescription pain medications.

D) Incorrect. Sedatives are drugs that calm or soothe and can also induce sleep.

A. Loss of appetite B. Insomnia C. Emotional lability D. Anxiety

Correct Answer is C

Explanation

A. Loss of appetite can be a symptom of PMDD, but it is not the primary manifestation.
B. Insomnia can be a symptom of PMDD, but it is not the primary manifestation.
C. Emotional lability, or rapid and intense mood swings, is a primary manifestation of PMDD.
D. Anxiety can be a symptom of PMDD, but it is not the primary manifestation.

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A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Nursing Test Bank

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