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 []
Explanation
Correct Answers:
Condition Most Likely Experiencing: C
Actions to Take: A, B
Parameters to Monitor: B, C
Rationale:
Condition Most Likely Experiencing
A. Pyloric stenosis causes projectile vomiting, dehydration, and hunger.
B. Cystic fibrosis causes chronic respiratory infections, steatorrhea, and failure to thrive.
C. The condition that the infant is most likely experiencing is congestive heart failure, which can cause poor weight gain, tachypnea, decreased appetite, and periorbital edema.
D. Respiratory syncytial virus bronchiolitis causes wheezing, coughing, and respiratory distress.
Actions to Take
A. Elevating the head of the bed can help reduce the workload of the heart and improve breathing.
B. Digoxin can increase the contractility of the heart and decrease the heart rate.
C. Contact precautions are not indicated for congestive heart failure, but for infections that are transmitted by direct or indirect contact.
D. Chest physiotherapy and postural drainage are not indicated for congestive heart failure, but for conditions that cause excessive mucus production and retention.
Parameters to Monitor
A. Number of steatorrhea stools is not relevant for congestive heart failure, but for cystic fibrosis or other malabsorption disorders.
B. Intake and output can indicate fluid balance and renal function.
C. Respiratory status can reflect cardiac function and oxygenation.
D. Presence of periorbital edema is not a parameter to monitor, but a sign of fluid overload.
Correct Answer is B
Explanation
Rationale:
A. While EMLA cream can provide local anesthesia, it takes time to take effect and might not be practical for immediate use before administering immunizations.
B. Providing a pacifier coated with an oral sucrose solution has been shown to reduce pain and stress during immunizations in infants, promoting atraumatic care.
C. Injecting immunizations into the deltoid muscle is a common practice, but it does not specifically address atraumatic care.
D. Using a smaller gauge needle (e.g., 22-25 gauge) is generally recommended for infants to minimize pain, but specifying a 20-gauge needle is not necessarily related to atraumatic care.
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