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 A
Explanation
Rationale:
A. This is the priority action to confirm the correct placement of the NG tube in the stomach before administering the enteral feeding.
B. This should only be done after confirming proper tube placement.
C. Flushing the tube is necessary, but it should occur after confirming placement.
D. This should occur after confirming proper tube placement.
Correct Answer is A
Explanation
Rationale:
A. A toddler who has a heart rate of 68/min is likely to have bradycardia, a slow heart rate that can affect oxygen delivery. Bradycardia could be caused by hypoxia, hypothermia, or cardiac problems. The nurse should report this finding to the provider immediately.
B. This temperature is within the normal range, so it does not require reporting.
C. This blood pressure is within the normal range for an adolescent, so it does not require reporting.
D. The normal respiratory rate for a 3-month-old infant is 25 to 40/min.
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