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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is d. Hallucinations.

Choice A reason: Hypothermia is not typically associated with MDMA use. Instead, MDMA can cause hyperthermia due to its stimulant effects.

Choice B reason: Muscle weakness is not a common effect of MDMA. The drug is more likely to cause increased energy and endurance.

Choice C reason: Somnolence, or a strong desire for sleep, is unlikely with MDMA use as it is a stimulant and tends to increase alertness.

Choice D reason: Hallucinations are a known effect of MDMA use, where users may experience distortions in perception. Methylenedioxy-methamphetamine (MDMA) is known to cause perceptual changes, including hallucinations.

A. "I should enable the airbag when my baby is in the front seat of the car.” B. "I should position the car seat's retainer clip at the level of my baby's belly button.” C. "I should keep my baby rear-facing in the car seat until she is 2 years old.” D. "I should place my baby in the car seat at a 90-degree angle.”

Correct Answer is C

Explanation

Choice A rationale:

Enabling the airbag when the baby is in the front seat of the car is incorrect. Airbags can be dangerous for infants and young children, and it is recommended to keep them in the rear seat, preferably in a rear-facing car seat.

Choice B rationale:

Positioning the car seat's retainer clip at the level of the baby's belly button is incorrect. The retainer clip should be at armpit level to ensure proper positioning and safety.

Choice C rationale:

Keeping the baby rear-facing in the car seat until she is 2 years old is the correct understanding of car seat safety. This statement aligns with the American Academy of Pediatrics (AAP) recommendations, which suggest keeping infants rear-facing as long as possible, ideally until they reach the maximum height and weight limits of their car seat.

Choice D rationale:

Placing the baby in the car seat at a 90-degree angle is incorrect. The correct angle for a rear-facing car seat depends on the manufacturer's guidelines but typically ranges from 30 to 45 degrees. The 90-degree angle is not safe and can compromise the baby's airway.

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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?

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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?