A client reporting fatigue and lack of pleasure in daily activities meets criteria for a diagnosis of major depressive disorder. What risk should be assessed first?
Chronic medical conditions contributing to fatigue.
Financial struggles.
Social isolation and lack of support.
Suicidal ideations and intent.
The Correct Answer is D
Choice A reason: Assessing for chronic medical conditions is an important part of a holistic physical exam to rule out secondary causes of depression, such as hypothyroidism or anemia. However, physiological assessments are secondary to the immediate psychological safety of a client presenting with core symptoms of major depression.
Choice B reason: Financial struggles are significant psychosocial stressors that can exacerbate depressive symptoms and affect access to care. While important for social work referrals and discharge planning, financial status does not present an immediate threat to the client's physical life during the initial nursing assessment.
Choice C reason: Social isolation is a known risk factor for the development and maintenance of depressive disorders. While the nurse should evaluate the client's support system to determine their level of resource availability, this assessment is lower in priority than identifying active, life-threatening psychiatric emergencies.
Choice D reason: Suicidal ideation is the most critical risk associated with major depressive disorder. Because the safety of the patient is the foundation of all nursing care, the nurse must first determine if the client has thoughts of self-harm, a specific plan, or the means to carry it out.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A reason: While increasing social interactions is a helpful component of the recovery process to combat isolation, it is not the primary clinical objective of the continuation phase. Socialization is a behavioral goal that follows the stabilization of mood through more foundational biological and psychological interventions.
Choice B reason: Electroconvulsive therapy is typically reserved for treatment-resistant depression or patients in an acute crisis who require a rapid response. It is not a standard emphasis for the continuation phase, which focuses on maintaining the remission achieved during the acute phase of treatment.
Choice C reason: Hospitalization is an intervention for the acute phase of major depressive disorder, especially when there is a risk of self-harm. The continuation phase occurs after the client has been stabilized, usually in an outpatient setting, making hospitalization an inappropriate focus for this stage of care.
Choice D reason: The continuation phase lasts 4 to 9 months after symptoms have subsided. The primary goal is to prevent relapse. Therefore, the nurse must emphasize strict adherence to the prescribed pharmacological regimen and consistent attendance at psychotherapy sessions to ensure the brain’s neurochemical balance remains stable.
Correct Answer is A
Explanation
realizes their potential, copes with normal stresses, and works productively. In contrast, mental illness involves clinically significant disturbances in cognition, emotional regulation, or behavior that reflect dysfunction in psychological processes, often resulting in impaired social or occupational functioning.
Choice B reason: Mental health and mental illness are not synonymous; they exist on a continuum. A person can have poor mental health without having a diagnosable mental illness, and conversely, a person with a chronic mental illness can achieve a high level of mental wellness through effective management and coping strategies.
Choice C reason: This statement is medically inaccurate because mental illness can manifest at any stage of the lifespan. Neurodevelopmental disorders, such as autism spectrum disorder or early-onset bipolar disorder, often appear in childhood or early adolescence. Age 20 is not a diagnostic threshold for the onset of psychiatric pathology.
Choice D reason: Mental illness is not simply a result of "poor mental health." Most mental illnesses have complex etiologies involving genetic predispositions, neurobiological imbalances, and environmental stressors. Poor mental health may be a precursor to or a symptom of illness, but it is not the sole causative factor for clinical disorders.
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