A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

Recall methods that were most successful in the past.

Turn to other activities to take one's mind off of the issues.

Reach out to family and friends about feelings of abandonment.

Relax and reduce the amount of effort to solve the problem.

Answer and Explanation

The Correct Answer is A

A) Recalling methods that were most successful in the past is an effective coping strategy. This approach encourages the client to identify and utilize strategies that have previously helped them manage their depression. It fosters a sense of agency and can inspire motivation to engage in positive behaviors again.

B) Turning to other activities to take one's mind off of the issues may provide temporary relief, but it does not address the underlying issues related to depression. This strategy could lead to avoidance rather than active problem-solving and engagement with life.

C) Reaching out to family and friends about feelings of abandonment is important for social support; however, it may not be the first step in the coping strategy. The client may need to develop skills to articulate their feelings before reaching out, and it also doesn’t directly address their current disengagement from activities.

D) Relaxing and reducing the amount of effort to solve the problem may feel appealing but could reinforce avoidance behaviors. It’s crucial to encourage the client to engage actively with their emotions and challenges instead of stepping back entirely. The goal should be to empower the client to take small, manageable steps toward re-engagement with life, making option A the most suitable choice.

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Correct Answer is D

Explanation

A) Reviewing the healthcare provider's history and physical may provide some background on the client's overall health and medication history, but it won't specifically address the symptoms currently being observed. While this information is useful, it does not directly relate to the assessment of involuntary movements.

B) The baseline nursing admission assessment can offer insights into the client's initial condition and any prior neurological assessments. However, it may not contain the specific details necessary to evaluate the current symptoms of uncontrollable hand movements and tongue protrusion, which are indicative of potential tardive dyskinesia or other movement disorders.

C) Recent urine drug testing (UDT) results could help identify any illicit substance use or non-compliance with prescribed medications. However, UDT results would not provide a clear correlation to the motor symptoms observed. Understanding the client’s current medication compliance is important, but it is not as directly relevant as the assessment of involuntary movements.

D) Reviewing the Abnormal Involuntary Movement Scale (AIMS) is crucial, as it specifically assesses involuntary movements associated with the use of antipsychotic medications and other psychotropic drugs. AIMS can provide baseline data and track any changes in involuntary movements over time. Given the client's symptoms of uncontrollable hand movements and excessive tongue protrusion, AIMS results will be key to determining if the client is experiencing tardive dyskinesia or other medication-related side effects.

A. Return at a later time to talk. B. Ask a different question. C. Wait for the client to respond. D. Ask if the client heard the question.

Correct Answer is C

Explanation

A) Returning at a later time to talk might seem considerate, but it may miss the opportunity to engage with the client in the moment. The client may benefit from having the nurse's presence and support, even if they are slow to respond.

B) Asking a different question could disrupt the process and prevent the client from expressing their feelings. It’s important to allow the client the space to answer the original question rather than shifting topics prematurely.

C) Waiting for the client to respond is the best action. This approach demonstrates patience and respect for the client's current state. By allowing time for a response, the nurse can create a supportive environment, which may help the client feel more comfortable opening up when they are ready.

D) Asking if the client heard the question might feel like an interruption or could add pressure, making the client more anxious. It’s better to give the client space to process and respond without feeling judged or rushed.

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A client with depression is not attentive to personal hygiene, uses television watching as a means of escape from responsibilities, and describes an inability to enjoy the things that once gave them pleasure. Which coping strategy should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client's record should the nurse review?

Correct Answer is D

Explanation

The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

Correct Answer is C

Explanation

The nurse is assessing a client with postpartum depression for changes in the mood and cognitive state. Which subjective finding(s) should the nurse identify that are consistent with postpartum depression? Select all that apply.

After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

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

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client's rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

A young adult client is brought to the emergency department with a suspected drug overdose. Which information is most important for the nurse to obtain from the family?