A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?

"Tell me what makes you feel stressed.”.

"How have you dealt with stress in the past?".

"Let's talk more about what you are experiencing.”.

"Are you thinking of harming yourself?". .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking the client to describe what makes them feel stressed is important for understanding their situation, but it is not the immediate priority when there is concern about self-harm.

Choice B rationale:

Inquiring about the client's past coping mechanisms is relevant, but it should not be the first question when there is a potential risk of self-harm.

Choice C rationale:

Discussing what the client is experiencing is important, but it is not the primary concern when there is a risk of self-harm.

Choice D rationale:

Asking the client if they are thinking of harming themselves is the immediate priority in this situation. It helps assess the client's safety and the need for further intervention. Please let me know if you have more questions or need further explanations. .

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Correct Answer is C

Explanation

Choice A rationale:

The Generalized Anxiety Disorder 7 (GAD-7) is not the appropriate assessment tool for measuring the severity and impact of depression in a patient with major depressive disorder (MDD). GAD-7 is specifically designed to assess generalized anxiety disorder, not depression. It asks questions related to anxiety symptoms, such as excessive worrying, restlessness, and irritability, which are different from the symptoms of depression.

Choice B rationale:

The Beck Anxiety Inventory (BAI) is not the appropriate assessment tool for measuring the severity and impact of depression. BAI is designed to assess the severity of anxiety symptoms, not depression. It includes questions about symptoms like nervousness, fear, and trembling, which are more related to anxiety rather than depression.

Choice D rationale:

The CAGE questionnaire is not an appropriate tool for assessing the severity and impact of depression. The CAGE questionnaire is primarily used to screen for alcohol use disorder. It consists of questions related to alcohol consumption and is not relevant for evaluating depression in patients with major depressive disorder.

Choice C rationale:

The Patient Health Questionnaire-9 (PHQ-9) is the most suitable assessment tool for measuring the severity and impact of depression in a patient with major depressive disorder (MDD). The PHQ-9 is a self-administered questionnaire that assesses the nine core symptoms of depression. It includes questions related to mood, energy level, concentration, and thoughts of self-harm, making it a comprehensive tool for assessing depression. It is widely used in clinical practice and research to determine the severity of depression and monitor treatment outcomes.

A. Monitoring signs of psychomotor agitation. B. Assessing the patient's memory and attention. C. Documenting the patient's medication history. D. Measuring vital signs and laboratory tests. E. Observing signs of impaired judgment.

Correct Answer is ["A","B","C","D","E"]

Explanation

Choice A rationale:

Monitoring signs of psychomotor agitation is an important aspect of assessing a patient with bipolar disorder. Psychomotor agitation is a common feature of bipolar disorder, and recognizing its signs can help in managing the patient's condition effectively.

Choice B rationale:

Assessing the patient's memory and attention is crucial in the assessment of bipolar disorder. It helps in evaluating cognitive function, which can be affected during manic or depressive episodes in bipolar disorder.

Choice C rationale:

Documenting the patient's medication history is essential when assessing a patient with bipolar disorder. Knowing the medications the patient is currently taking, as well as their medication history, is vital for understanding their treatment plan and ensuring the safe and effective management of the condition.

Choice D rationale:

Measuring vital signs and laboratory tests is an integral part of the physical assessment for a patient with bipolar disorder. Bipolar disorder can have physical health implications, and monitoring vital signs and conducting laboratory tests can help identify any underlying medical issues or side effects of medication.

Choice E rationale:

Observing signs of impaired judgment is another important aspect of assessing a patient with bipolar disorder. Impaired judgment can be a characteristic feature during manic episodes, and recognizing it is crucial for the safety and well-being of the patient.

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.I can't take it anymore.”. Which of the following responses should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a patient with major depressive disorder (MDD). Which assessment tool can the nurse use to measure the severity and impact of depression on the patient’s functioning?

Correct Answer is C

Explanation

A nurse is assessing a patient with bipolar disorder.Which of the following aspects of the assessment should the nurse consider as part of the physical assessment? Select all that apply:.

Correct Answer is ["A","B","C","D","E"]

Explanation

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?