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 C

Explanation

A) Impaired comfort is a relevant concern, but it is not the highest priority in the context of a potentially life-threatening situation such as aspiration of a caustic material. While comfort is important, it is secondary to immediate safety and physiological needs.

B) Risk for injury is a general concern in many situations, but in this specific case, it does not address the acute medical implications of the aspiration of caustic material. While injury could occur, the focus should be on the immediate effects of the incident.

C) Ineffective breathing pattern is the highest priority nursing problem. Aspiration of caustic material can lead to severe respiratory complications, including airway obstruction, chemical pneumonitis, and other respiratory distress. Ensuring the client has adequate ventilation and monitoring for signs of respiratory distress are critical nursing interventions that take precedence over other concerns.

D) Ineffective coping is important to address, particularly given the context of a suicide attempt; however, it is not as immediate as the potential life-threatening consequences of aspiration and ineffective breathing. The client’s physical safety must be prioritized before addressing psychological issues.

A. Administer a PRN analgesic to the client. B. Further assess the client's pain and vital signs. C. Ask if the client to compare this pain to the pain in the past. D. Remind the client that the symptoms are psychological in cause.

Correct Answer is B

Explanation

A) Administering a PRN analgesic may provide temporary relief but does not address the need for a comprehensive assessment of the client's condition. It is essential to understand the nature and cause of the chest pain before treating it.

B) Further assessing the client's pain and vital signs is the most appropriate action. This allows the nurse to gather important clinical information that can help determine whether the chest pain is related to a medical condition or is part of the somatic symptom disorder. A thorough assessment is critical in ensuring the client's safety and addressing any potential underlying health issues.

C) Asking the client to compare this pain to past pain can provide context but is not a priority action. The immediate focus should be on assessing the current situation rather than reflecting on past experiences.

D) Reminding the client that the symptoms are psychological in cause can be invalidating and may hinder the therapeutic relationship. It is crucial to approach the client with empathy and understanding, rather than dismissing their experience.

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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

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

Correct Answer is C

Explanation

A client with somatic symptom disorder reports experiencing chest pain to the nurse. Which action should the nurse take?

Correct Answer is B

Explanation

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?

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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?