A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Risk for suicide

Risk for injury

Powerlessness

Risk for imbalance nutrition

Answer and Explanation

The Correct Answer is A

A. Priority. The patient is exhibiting severe depression, weight loss, and expressing hopelessness, which are all indicators of an increased risk for suicide. Assessing and addressing the risk for suicide is crucial to ensuring the safety and well-being of the patient.

B. Incorrect. While the patient may be at risk for injury due to factors such as poor nutrition and potential self-harm, the immediate concern in this case is the risk for suicide, given the patient's severe depression and expressed hopelessness.

C. Incorrect. Powerlessness may be a relevant nursing diagnosis for individuals experiencing depression, but the immediate concern in this case is the risk for suicide. Addressing the patient's sense of powerlessness can be part of the broader care plan, but it's not the priority.

D. Incorrect. While the patient has experienced significant weight loss, the priority at this time is addressing the risk for suicide. Once the immediate safety concern is addressed, nutritional concerns can be addressed as part of the overall care plan.

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Correct Answer is B

Explanation

A. fluoxetine (Prozac):

Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression and anxiety disorders. While SSRIs can have side effects, significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance are not typically associated with fluoxetine. The primary concerns with SSRIs are related to serotonin levels and can include gastrointestinal disturbances, insomnia, and sexual dysfunction.

B. Lithium (Lithobid):

This is the correct answer. Lithium is known to have potential side effects related to cardiac and cerebral function, as well as fluid and electrolyte balance. Monitoring blood levels of lithium is crucial to avoid toxicity, which can affect the cardiovascular and central nervous systems. Lithium toxicity can lead to symptoms such as tremors, confusion, ataxia, and, in severe cases, seizures.

C. venlafaxine (Effexor):

Venlafaxine is a serotonin-norepinephrine reuptake inhibitor (SNRI) commonly used to treat depression and anxiety disorders. While it can cause some cardiovascular effects, the concern for significant alterations in cardiac or cerebral electrical conductivity and fluid/electrolyte imbalance is generally lower compared to lithium. The primary side effects of venlafaxine are related to serotonin and norepinephrine levels and may include increased blood pressure and heart rate.

D. clozapine (Clozaril):

Clozapine is an atypical antipsychotic medication used to treat schizophrenia. While antipsychotics can have side effects related to metabolic changes, significant alterations in cardiac or electrolyte imbalances are not typically associated with clozapine as the primary concern. Regular monitoring for metabolic side effects, such as weight gain and changes in lipid and glucose levels, is important with antipsychotic medications.

A. Provide personal space to respect the clients boundaries B. Maintain continual eye contact throughout the interview C. Provide neon lights and soft music D. use therapeutic touch to increase trust and rapport

Correct Answer is A

Explanation

A. Provide personal space to respect the client's boundaries: This is the correct answer. Personal space is crucial when caring for an agitated client with paranoia. Respecting the client's need for distance helps to reduce anxiety and prevent escalation of agitation.

B. Maintain continual eye contact throughout the interview: Continuous eye contact may be perceived as confrontational and can increase anxiety, especially in individuals with paranoia. It is important to be mindful of non-verbal cues and adapt the approach to the client's comfort level.

C. Provide neon lights and soft music: Introducing external stimuli like neon lights and music may not be appropriate for an agitated client with paranoia. It could potentially exacerbate their distress. The focus should be on creating a calm and non-threatening environment.

D. Use therapeutic touch to increase trust and rapport: While therapeutic touch can be beneficial in certain situations, it may not be suitable for a client experiencing paranoia. Touch can be perceived as intrusive and may escalate agitation in this context.

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A newly admitted patient is severely depressed, lost 20 pounds over the past month, and expresses hopelessness for the future. Select the priority nursing diagnosis

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and venlafaxine, respectively. For which patient should the nurse be most alert for alterations in cardiac or cerebral electrical conductivity as well as fluid and electrolyte imbalance? The patient receiving:

Correct Answer is B

Explanation

Which nursing intervention would be most appropriate when caring for an acutely agitated client with paranoia?

Correct Answer is A

Explanation

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