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.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. While informing the client to contact the pharmacy is appropriate, it does not address the immediate need for understanding the medication.
B. Providing instructions to the client's parent may not respect the adolescent's autonomy and privacy regarding their healthcare.
C. Instructing the client's parents to write down the information may not involve the adolescent in the learning process or address their individual needs.
D. Asking how the client prefers to learn new information demonstrates respect for the adolescent's autonomy and preferences, facilitating effective communication and understanding.
Correct Answer is D
Explanation
Rationale:
A. Chlorothiazide is a diuretic and is not indicated during a seizure.
B. Holding the child down during a seizure can lead to injury and is not recommended. It's essential to ensure the child's safety by protecting the head from injury and removing any objects that could cause harm.
C. Placing the child in a prone position during a seizure can compromise their ability to breathe and is not recommended. Instead, the child should be placed in a safe position on their side to prevent aspiration.
D. Timing the duration of the seizure is crucial for medical management and documentation purposes. This action allows healthcare providers to assess the
severity of the seizure and determine the need for intervention or medication administration.
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