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 ["2.2"]
Explanation
Step 1 is to calculate the total dose of ondansetron required. This is done by multiplying the child’s weight by the dose per kilogram. So, 29.4 kg × 0.15 mg/kg = 4.41 mg.
Step 2 is to calculate the volume of the solution required. This is done by dividing the total dose by the concentration of the solution. So, 4.41 mg ÷ (4 mg/2 mL) = 2.205 mL. The final calculated answer is that the nurse should administer approximately 2.2 mL of the ondansetron solution.
Correct Answer is B
Explanation
Choice A rationale
Covering the insertion site with an opaque dressing is not typically recommended for infants. Transparent dressings are usually preferred because they allow for easy inspection of the site for signs of infection or complications.
Choice B rationale
Using a 24-gauge catheter to start the IV is the correct action. This size is appropriate for a 12-month-old infant and will cause the least amount of discomfort and trauma to the vein.
Choice C rationale
Starting the IV on the infant’s foot is not typically recommended. The hands and arms are usually preferred sites for IV insertion in infants.
Choice D rationale
Changing the IV site every 3 days is not typically necessary unless there are signs of complications such as infection or infiltration. Frequent site changes can cause unnecessary discomfort and trauma to the infant.
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