A nurse is collecting data from a group of clients who have major depressive disorder.
The nurse should identify that which of the following clients is at the greatest risk for suicide?
A client who has psychomotor retardation.
A client who reports an inability to concentrate.
A client who exhibits an increase in energy.
A client who experiences persistent insomnia.
The Correct Answer is C
The correct answer is: c. A client who exhibits an increase in energy.
Choice A reason: A client with psychomotor retardation may experience a visible slowing of physical and emotional reactions. This symptom is associated with major depressive disorder and can manifest as slowed speech, decreased movement, and impaired cognitive function. While psychomotor retardation is a significant symptom of depression, it is not typically identified as the highest risk factor for suicide when compared to other symptoms such as a sudden increase in energy, which can indicate a potential for acting on suicidal thoughts.
Choice B reason: An inability to concentrate is another symptom that can be present in individuals with major depressive disorder. It refers to difficulty in focusing, making decisions, or remembering things. Although this can contribute to the overall severity of depression, it is not directly linked to an increased risk of suicide as strongly as some other symptoms like changes in sleep patterns or behavior.
Choice C reason: An increase in energy in a client with major depressive disorder, especially if it occurs suddenly, can be a warning sign of potential suicidal behavior. This change can indicate that the individual has decided about suicide and may now have the energy to act on these thoughts. It is important for healthcare providers to closely monitor such changes in energy levels, as they can be indicative of an increased risk for suicide.
Choice D reason: Persistent insomnia is a common symptom in individuals with major depressive disorder and can exacerbate other symptoms of depression. Lack of sleep can lead to irritability, cognitive impairment, and can affect overall health. While it is a concerning symptom and can affect a person’s risk for suicide, it is not considered the single highest risk factor when compared to a sudden increase in energy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Ice cream. Ice cream is not typically recommended for individuals with irritable bowel syndrome (IBS) as it contains dairy, which can exacerbate gastrointestinal symptoms in some people with lactose intolerance or dairy sensitivity. It may also be high in sugar, which can worsen IBS symptoms for some individuals.
Choice B rationale:
Honey. Honey is generally well-tolerated by individuals with IBS and can be used as a natural sweetener in moderation. However, it is not specifically recommended as a dietary inclusion for managing IBS symptoms.
Choice C rationale:
Watermelon. Watermelon is a low-fiber fruit that may be well-tolerated by some individuals with IBS, especially during periods of symptom flare-ups. However, it does not provide the beneficial probiotics and digestive enzymes found in yogurt, which can be helpful for some IBS patients.
Choice D rationale:
Yogurt. Yogurt, especially varieties containing live probiotic cultures, can be beneficial for individuals with IBS. Probiotics may help improve gut health and alleviate some gastrointestinal symptoms associated with IBS. It is often recommended as a dietary inclusion for those with IBS.
Correct Answer is D
Explanation
Choice A rationale:
Hyperglycemia is not typically associated with tranylcypromine, a monoamine oxidase inhibitor (MAOI) MAOIs can affect blood pressure regulation, but hyperglycemia is not a common adverse effect of this medication.
Choice B rationale:
Hematuria (blood in the urine) is not a known adverse effect of tranylcypromine. This symptom is not directly related to the use of MAOIs.
Choice C rationale:
Tinnitus (ringing in the ears) is not a common adverse effect of tranylcypromine. MAOIs can affect the cardiovascular system, but tinnitus is not a typical manifestation.
Choice D rationale:
Tranylcypromine, an MAOI, can cause hypertension (high blood pressure) as an adverse effect due to its ability to inhibit the breakdown of tyramine in the body. When tyramine-rich foods are ingested, there can be a sudden release of norepinephrine, leading to a hypertensive crisis. Therefore, monitoring for hypertension is essential when a client is taking tranylcypromine and has ingested tyramine-rich foods.
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