A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?

Administer an antidepressant to the client.

Assist the client in completing his ADLs.

Ask the client if he is considering harming himself.

Encourage the client to attend a group therapy session.

Answer and Explanation

The Correct Answer is C

A. Administering an antidepressant is an important intervention for a client with major depressive disorder. However, before initiating any treatment, it is crucial to assess the client's risk for self-harm or suicidal ideation.

B. Assisting the client in completing activities of daily living (ADLs) is important for their overall well-being, but the most immediate concern for a client with major depressive disorder is to assess their safety and risk for self-harm.

C. Correct. Assessing the client's risk for self-harm or suicidal ideation is the first priority.
This information will help determine the level of intervention and support needed.

D. Encouraging the client to attend group therapy is a valuable intervention, but it is not the first priority. Safety concerns must be addressed before implementing other
therapeutic interventions.

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Correct Answer is A

Explanation

A. This is the correct intervention. Children with autism spectrum disorder may have difficulty with social interactions and may become overwhelmed by prolonged or intense interactions. Keeping staff visits brief allows for positive interactions while minimizing potential stress for the child.

B. Children with autism spectrum disorder often thrive on routines and predictability.
Varying daily routines can be distressing and may lead to increased anxiety.

C. Placing the child in a semi-private room may expose them to additional stimuli and potential social interactions, which can be overwhelming for a child with an autism spectrum disorder. A private room may provide a quieter and more controlled environment.

D. Background noise, such as from a television, can be overstimulating for a child with autism spectrum disorder. It is generally recommended to provide a quiet environment to help the child feel more comfortable and at ease.

A. Perform developmental testing for delays. B. Initiate a low-iron diet for lead absorption. C. Obtain a stool specimen for lead levels. D. Inspect the skin for discoloration.

Correct Answer is A

Explanation

A. Toddlers with a history of lead poisoning are at risk for developmental delays.
Developmental testing can help identify any delays that may require intervention or support.

B. Lead absorption is not related to iron intake. However, a diet rich in iron can help reduce the absorption of lead.

C. Blood testing, not stool testing, is the primary method for assessing lead levels. Blood lead levels provide the most accurate information about lead exposure.

D. While lead poisoning can cause changes in skin color in severe cases, it is not the primary assessment for lead exposure. Blood lead levels and developmental testing are more indicative of lead poisoning.

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A nurse is caring for an adolescent who has a major depressive disorder. Which of the following actions should the nurse take first?

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