A nurse is caring for a client who has depression. After two days of treatment, the nurse notices that the client is suddenly more active and there are no longer signs of a depressive state. Which of the following interventions should the nurse recommend for the plan of care?
Encourage family to take the client out of the facility for short periods of time.
Reward the client for her change in behavior.
Ask the client why her behavior has changed.
Monitor the client's whereabouts at all times.
The Correct Answer is D
Choice A reason: While it may be beneficial for the client's mood, taking the client out of the facility does not directly address the sudden change in behavior.
Choice B reason: Rewarding the client for a change in behavior does not address the potential risks associated with a sudden change in mental status.
Choice C reason: Asking the client why their behavior has changed could be part of an assessment, but it is not an immediate safety intervention.
Choice D reason: Monitoring the client's whereabouts at all times is important as a sudden lift in depressive symptoms can sometimes precede a suicide attempt, and close observation is necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A high potassium level can increase the risk of digoxin toxicity. The normal range for potassium is typically 3.5 to 5.0 mEq/L, so a level of 5.5 mEq/L should be reported.
Choice B reason: A potassium level of 3.8 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice C reason: A potassium level of 4.5 mEq/L is within the normal range and would not typically increase the risk of digoxin toxicity.
Choice D reason: A low potassium level can also increase the risk of digoxin toxicity, but the question asks for the result that does not increase the risk, making 2.9 mEq/L incorrect in this context.
Correct Answer is D
Explanation
Choice A reason: This response is a closed-ended question that might not encourage further discussion or reveal the underlying issues.
Choice B reason: This confrontational approach could make the patient defensive and is not conducive to building a therapeutic relationship.
Choice C reason: While encouraging the patient to eat is important, this directive does not address the patient's feelings or concerns.
Choice D reason: Asking an open-ended question invites the patient to share more about their feelings and can lead to a better understanding of their lack of appetite.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.