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 A

Explanation

Choice A rationale:

In an interprofessional team meeting for a client, it is essential to include information about changes in the client's condition or any new developments that may impact their care. The statement that "The client has developed difficulty ambulating" is relevant as it indicates a change in the client's mobility status and may require additional interventions or assessments.

Choice B rationale:

The timing of the client's next dressing change (scheduled in 4 hr) is important information but may not be the highest priority to discuss in an interprofessional team meeting. It is more pertinent to focus on the client's current condition and any changes that have occurred.

Choice C rationale:

The client's health insurance status (state-sponsored health insurance) is not typically a central topic of discussion in an interprofessional team meeting unless it directly affects the client's care plan or access to specific treatments.

Choice D rationale:

The frequency of the client's vital sign checks (every 8 hr) is important information for the healthcare team to be aware of, but it may not be the most critical piece of information to include in the interprofessional team meeting. Changes in vital signs or trends would be more relevant to discuss.

A. Replace the IV pump's tubing. B. Clear the settings and reset the IV pump. C. Plug the IV pump's cord into a different outlet. D. Discontinue use and tag the IV pump.

Correct Answer is D

Explanation

Choice A rationale:

Replace the IV pump's tubing. Replacing the IV pump's tubing is not the appropriate action when the IV pump screen is malfunctioning. Malfunctioning tubing does not typically affect the pump's screen or settings.

Choice B rationale:

Clear the settings and reset the IV pump. Clearing the settings and resetting the IV pump may not be effective if the screen is malfunctioning. It is important to ensure the accuracy and safety of IV fluid administration, and troubleshooting the screen is not a reliable solution in the case of a malfunction.

Choice C rationale:

Plug the IV pump's cord into a different outlet. Changing the outlet may help if the issue is related to electrical power, but it is not the most appropriate action when the IV pump screen is malfunctioning. Safety concerns and potential equipment issues warrant discontinuing use and tagging the pump.

Choice D rationale:

Discontinue use and tag the IV pump. When the IV pump screen is malfunctioning, the safest and most appropriate action is to discontinue its use and tag the pump. This ensures that the malfunctioning equipment is not used on other patients and that a thorough inspection and repair can be conducted to prevent potential harm to the patient.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is participating in an interprofessional team meeting for a client.Which of the following information about the client should the nurse include?

Correct Answer is A

Explanation

A nurse is providing a client with IV fluids and finds that the IV pump screen is malfunctioning.Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?

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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 reviewing the medical records of five clients. For which of the following events should the nurse write an incident report? (Select all that apply.)

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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?