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 C
Explanation
Choice A rationale
Children with autism spectrum disorder often thrive on routines and predictability. Varying daily routines can be distressing and may lead to increased anxiety.
Choice B rationale
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.
Choice C rationale
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.
Choice D rationale
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.
Correct Answer is B
Explanation
Choice A rationale
A rectal body temperature of 37.3 C (99.1 F) in a school-age child is within the normal range, so it does not need to be reported.
Choice B rationale
A heart rate of 68/min in an 18-month-old toddler is below the normal range (80-130 beats per minute). This could indicate a serious condition such as heart block or hypothermia and should be reported to the provider.
Choice C rationale
A blood pressure of 132/82 mm Hg in an adolescent is slightly elevated but within acceptable limits for a teenager, especially if the teenager was nervous or anxious during the measurement.
Choice D rationale
A respiratory rate of 36/min in a 3-month-old infant is within the normal range (30-60 breaths per minute), so it does not need to be reported.
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.