A nurse is caring for an adolescent who has major depressive disorder.
Which of the following actions should the nurse take first?
swer and explanation
Encourage the client to attend a group therapy session
Assist the client in completing his ADLs
Ask the client if he is considering harming himself
The Correct Answer is D
Choice A rationale
Administering an antidepressant to the client is an important part of treatment for major depressive disorder. However, it is not the first action the nurse should take.
Choice B rationale
Encouraging the client to attend a group therapy session can be beneficial for the client’s recovery, but it is not the first action the nurse should take.
Choice C rationale
Assisting the client in completing his ADLs can help the client maintain a sense of normalcy and control, but it is not the first action the nurse should take.
Choice D rationale
Asking the client if he is considering harming himself is the first action the nurse should take. This is because safety is the top priority, and the nurse needs to assess the client’s risk for suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"xRanges":[313.765625,383.765625],"yRanges":[279.609375,349.609375]}
Explanation
Choice B rationale
Patent ductus arteriosus (PDA) is a condition where the opening between the two major blood vessels leading from the heart fails to close after birth. In the womb, this opening, known as the ductus arteriosus, is a normal part of the baby’s circulatory system. It usually closes shortly after birth. If it remains open, it’s called a patent ductus arteriosus.
Correct Answer is A
Explanation
Choice A rationale
A weak pedal pulse distal to the site of a cardiac catheterization procedure could indicate a vascular complication, such as a hematoma or thrombosis, and should be reported to the provider immediately.
Choice B rationale
A blood pressure of 102/58 mm Hg is within the normal range for a toddler and does not need to be reported to the provider.
Choice C rationale
Bilateral cool extremities can be a normal finding in a child who is recovering from anesthesia. However, if coolness is accompanied by other signs of poor perfusion, such as pallor or delayed capillary refill, it should be reported to the provider.
Choice D rationale
A serum glucose level of 90 mg/dL is within the normal range for a toddler and does not need to be reported to the provider.
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