A nurse in an acute care mental health facility is caring for a client who has depression. After 3 days of treatment, the client suddenly seems cheerful and relaxed, and there are no longer signs of a depressive state. Which of the following interventions is appropriate to include in the plan of care?
Ask the client why her behavior has changed.
Reward the client for her change in behavior.
Monitor the client's whereabouts at all times.
Encourage the family to take the client out of the facility for short periods of time.
The Correct Answer is C
A. While it is important to understand changes in behavior, the sudden shift from depression to a cheerful state could be indicative of a potential risk, such as a plan to self-harm, particularly if the client is showing improved mood quickly.
B.It is not appropriate to reward a change in behavior without understanding the underlying reasons for the change. The sudden improvement in mood could be a sign of a potential risk, such as suicidal ideation or a temporary lift in mood before a possible crisis.
C. This is a crucial intervention. A sudden change in mood can sometimes be associated with an increased risk of self-harm or suicidal ideation, particularly if the client’s mood improves significantly before a more stable improvement in their depressive symptoms. Continuous monitoring helps ensure the client’s safety.
D.This could be premature and potentially unsafe, given the sudden and significant change in the client's condition. It is more important to ensure that the client’s mood change is not indicative of an underlying risk before allowing unsupervised activities.
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Related Questions
Correct Answer is D
Explanation
A. Panic. Panic-level anxiety typically involves extreme fear and severe physical symptoms such as palpitations, sweating, trembling, and a sense of impending doom. The client's reported symptoms (chest pain, headache, shortness of breath) do not align with the intense nature of panic anxiety.
B.Mild. Mild anxiety is characterized by heightened awareness and alertness. The client's symptoms and statement about his wife leaving him suggest more than mild anxiety as they indicate emotional distress beyond simple alertness.
C.Moderate. Moderate anxiety is associated with increased muscle tension, restlessness, and impaired concentration. Moderate anxiety (choice C) is characterized by increased alertness and decreased concentration but is manageable with support.
D. Severe anxiety significantly impairs daily functioning. It can cause physical symptoms such as chest pain, shortness of breath, and headaches. The client’s presentation aligns with severe anxiety, given the impact on his well-being.
Correct Answer is B
No explanation
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