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
The correct answer is choice c. Sunken anterior fontanel.
Choice A rationale:
A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.
Choice B rationale:
A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.
Choice C rationale:
A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.
Choice D rationale:
A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.
Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Placing gates at the top and bottom of stairs is an important safety measure for infants. This can prevent falls, which are a common cause of injury in this age group.
Choice B rationale
Ensuring the crib mattress is in the lowest position is another important safety measure. As infants grow and begin to sit, stand, and climb, a high mattress position can increase the risk of falls.
Choice C rationale
Removing labels from containers that contain toxic substances is not recommended. It’s important to keep these substances out of reach of children, and the labels provide important information about the contents and potential hazards.
Choice D rationale
Keeping toilet lids in the upright position is not recommended. Infants can be curious and may try to explore or play with water in the toilet, which can lead to accidents or injuries.
Choice E rationale
Selecting a toy chest that has a heavy, hinged lid is not recommended. This could pose a risk of injury if the lid were to close unexpectedly, and small fingers could get caught.
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