A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Refer the client to a mental health care provider for evaluation and treatment.

Determine the presence and degree of suicidal risk.

Identify support groups in the community for long-term treatment.

Assist the client to identify negative effects of chemical dependency.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.

Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.

Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.

Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.

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Correct Answer is A

Explanation

Choice A reason:
This statement is accurate and reflects effective teaching. Bupropion, like many antidepressants, can take several weeks to reach its full therapeutic effect. Informing patients about this delay is important to set realistic expectations and to encourage adherence to the medication regimen.

Choice B reason:
This statement is not entirely accurate. While moderate alcohol consumption may be permissible for some patients taking bupropion, it is generally advised to avoid or limit alcohol intake due to the risk of seizures and other side effects. Alcohol can also worsen depression symptoms and interact with the medication.

Choice C reason:
This statement is incorrect. Bupropion does not typically cause bradycardia (slow heartbeat). Instead, it can cause tachycardia (fast heartbeat) as a side effect. Patients should be informed about the potential cardiovascular effects of bupropion, including an increased heart rate.

Choice D reason:
This statement is incorrect. Increased salivation and drooling are not common side effects of bupropion. The medication is more commonly associated with dry mouth. Effective teaching would include informing the patient about the more likely side effects, such as dry mouth, insomnia, and headaches.

A. "The unit rules state that you may not remain in bed." B. "You can remain in bed until you feel well enough to join the group." C. "I will assist you in getting out of bed and getting dressed." D. "If you don't participate in your care, you will not get better."

Correct Answer is C

Explanation

Choice A reason:
This choice represents an authoritative approach, which may not be effective with a depressed client who is refusing therapy and ADLs. It does not offer support or understanding of the client's condition and may exacerbate feelings of helplessness or resistance to care.

Choice B reason:
While this statement offers a degree of autonomy to the client, it lacks the active encouragement and assistance that might be necessary to motivate a client who is depressed. It does not address the importance of participating in therapy or ADLs for the client's recovery.

Choice C reason:
This is the most therapeutic choice as it offers both support and a gentle nudge towards participation. It acknowledges the client's current state and provides a clear, immediate, and supportive next step. This approach can help reduce the client's feelings of being overwhelmed and can foster a sense of collaboration between the nurse and the client.

Choice D reason:
This statement, although factual, may come across as confrontational and could potentially discourage the client further. It does not provide the supportive framework that is crucial for engaging a client who is struggling with depression.

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A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

Correct Answer is A

Explanation

A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?

Correct Answer is C

Explanation

A nurse is caring for a client who is prescribed extended-release Morphine. The nurse should recognize which of the following assessment cues as an indication of opioid overdose?

A nurse in a hospital is caring for a client who has agoraphobia. Which of the following statements by the client indicates understanding of the goals of treatment?

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff on the unit as a follow-up to this incident?

A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?

A nurse is caring for a client who has been admitted with a suspected stimulant overdose. Which of the following nursing priorities should the nurse implement first?

A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?

A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?