A nurse is caring for an adolescent who has major depressive disorder. Which of the following actions should the nurse take first?
Ask the client if he is considering harming himself.
Encourage the client to attend a group therapy session.
Administer an antidepressant to the client.
Assist the client in completing his ADLs.
The Correct Answer is A
Rationale:
A. Assessing the risk of self-harm or suicide is the top priority when caring for a patient with major depressive disorder. It allows the nurse to intervene immediately if there's a risk of harm.
B. While group therapy can be beneficial for individuals with depression, it's not the first priority when assessing for safety concerns.
C. Administering antidepressants may be part of the treatment plan, but it's essential to assess the immediate risk of self-harm before proceeding with medication administration.
D. Assisting with activities of daily living is important, but it's not the first action to take when assessing for safety in a patient with major depressive disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Sweating is more commonly associated with hypoglycemia (low blood sugar) rather than hyperglycemia (high blood sugar).
B. Tremors are more commonly associated with hypoglycemia.
C. Pallor is not typically associated with hyperglycemia.
D. Thirst (polydipsia) is a classic symptom of hyperglycemia in diabetes mellitus, as the body tries to dilute the excess sugar in the bloodstream by increasing fluid intake.
Correct Answer is C
Explanation
Rationale:
A. While osteomyelitis is a serious condition requiring treatment, receiving an IV bolus of nafcillin is not an urgent procedure compared to a neurological symptom like slurred speech.
B. Pain management is important, but a pain level of 7, while significant, does not indicate an immediate life-threatening situation.
C. Slurred speech in an adolescent with sickle cell anemia could indicate a neurological complication or a stroke, which requires immediate assessment and intervention.
D. Although the toddler with a partial-thickness burn needs care, it is not as urgent as assessing a potential neurological issue like slurred speech.
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