A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?

The client will identify positive qualities about herself.

The client will identify ways to achieve a reachable goal for the future.

The client will identify her position in the grief process.

The client will contact a staff member when she feels she might hurt herself.

Answer and Explanation

The Correct Answer is D

D. This goal addresses the immediate safety and well-being of the client. Depression, especially severe depression, can increase the risk of suicidal ideation and behaviors. It is crucial to ensure the client's safety and have measures in place for her to reach out for help if she feels overwhelmed or unsafe.

A. While this is an important goal for improving self-esteem and mood, it may not be the highest priority when the client's safety is at risk.

B. This goal focuses on future planning and motivation, which is important for recovery but may not be as urgent as ensuring immediate safety.

C. Understanding one's grief process is important for emotional healing, but it is not typically as critical as ensuring safety in the immediate term.

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Correct Answer is B

Explanation

B. This is the most appropriate initial action. One-to-one observation ensures constant monitoring of the client's safety and prevents further harm, such as another suicide attempt or self-harm. Given the client's history of depression and recent suicide attempt, ensuring their safety is paramount.

A. This option is not the first priority because while addressing anorexia nervosa is important, safety concerns related to the suicide attempt and potential substance abuse take precedence. Making a weight gain contract requires the client's cooperation and readiness, which may not be feasible immediately upon admission.

C. While assessing the severity of depression is crucial, it is secondary to ensuring immediate safety in this context. The client's safety must be established first through continuous observation and intervention.

D. While important to understand the substances involved in the suicide attempt, this action is secondary to ensuring ongoing safety through direct observation. Toxicology results can guide subsequent treatment decisions but are not as urgent as immediate safety measures.

A. "It seems like you are feeling helpless about this behavior." B. "Do you have any idea why you do this?" C. "You should stop because you need to. You are destroying your health." D. "I'm proud of you for recognizing that this behavior is not normal."

Correct Answer is A

Explanation

A. This response acknowledges the client's feelings of helplessness, which can validate her experience and promote further discussion about her emotions and challenges related to her eating disorder. It shows empathy and encourages the client to explore her feelings.

B. While this question is open-ended and invites the client to explore the underlying reasons for her behavior, it might inadvertently suggest that the client should have insights or control over her behavior that she may not currently possess. It could potentially make the client feel blamed or misunderstood if she cannot provide a clear answer.

C. This response is directive and judgmental, which can lead to the client feeling criticized or defensive. It does not acknowledge the complexity of the client's experience and may not be effective in building rapport or promoting trust between the nurse and client.

D This response acknowledges the client's self-awareness and validates her recognition of the problem, which can be empowering and supportive. It reinforces the positive step the client has taken in acknowledging the issue without placing blame or judgment.

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A nurse is contributing to the plan of care for a client who has severe depression following the loss of her spouse. When identifying client goals, which of the following goals should the nurse identify as the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

Correct Answer is A

Explanation

The client has recently started antidepressant drug therapy. He approaches the nurse complaining of a headache, palpitations, and stiffness in the neck. What is the nurse's priority action?

A depressed client has been prescribed a selective serotonin reuptake inhibitor. Which medication may have been prescribed?

A male client who suffered a stroke completed his physical therapy and is returning to work. The client is in which stage of the illness experience?

A client has been given the diagnosis of bulimia. An appropriate medication used in the treatment of bulimia is which of the following?

Which instruction should the nurse give a client who is prescribed lithium carbonate (lithium)?

Hospitalization of a client with a dissociative disorder is required in which situation?

A client continually reports physical symptoms in the absence of objective clinical findings. The nurse should suspect which of the following disorders?