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. Providing for periods of rest is important to conserve energy in children with heart failure.
B. Increasing the oxygen flow rate until cyanosis resolves may not be appropriate without medical guidance.
C. Digoxin should not be withheld without consulting the healthcare provider. It is essential to follow the prescribed regimen and contact the provider if there are concerns about the child's pulse rate.
D. Weighing the child once each month may not be frequent enough for monitoring fluid status in a child with heart failure. More frequent weight monitoring may be necessary as per the healthcare provider's recommendations.
Correct Answer is B
Explanation
Rationale:
A. Capillary refill time of 3 seconds is within the normal range (less than 3 seconds) and does not indicate severe dehydration.
B. A sunken anterior fontanel is a significant sign of dehydration in infants and suggests severe dehydration.
C. While a weight loss of 5% can indicate dehydration, it may not necessarily represent severe dehydration. The extent of dehydration is better assessed by clinical signs such as fontanel status, skin turgor, and mucous membrane moisture.
D. Producing tears when crying is a reassuring sign and suggests adequate hydration, so it does not indicate severe dehydration.
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