A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care?

Encourage the client to sleep during the day to make up for insomnia.

Schedule a brisk physical activity before bedtime to facilitate sleep.

Monitor the client for bouts of diarrhea.

Offer the client frequent small snacks during waking hours.

Answer and Explanation

The Correct Answer is D

Choice A reason: Encouraging the client to sleep during the day can disrupt the normal sleep-wake cycle and is not recommended for managing insomnia associated with depression.

Choice B reason: Scheduling a brisk physical activity before bedtime can be stimulating and may actually make it more difficult for the client to fall asleep.

Choice C reason: Monitoring for bouts of diarrhea is not directly related to the care of a client with severe depression unless the client is on specific medications that may cause gastrointestinal upset as a side effect.

Choice D reason: Offering frequent small snacks can help manage the weight loss and decreased appetite often seen in clients with severe depression, ensuring they receive adequate nutrition.

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Correct Answer is C

Explanation

Choice A reason: While hostility and sarcasm can be challenging, they are not immediate safety concerns compared to the physical activity that could lead to exhaustion or injury.

Choice B reason: Giving away personal items and money can be concerning for the client's financial well-being, but it does not pose an immediate risk to their physical health.

Choice C reason: Pacing in the hallway during the day and most of the night could indicate a high level of psychomotor agitation associated with mania, which can lead to physical exhaustion or injury and is therefore a priority.

Choice D reason: Flight of ideas is a symptom of mania that, while important to note, does not pose an immediate risk to the client's safety like excessive physical activity does.

A. "I have gained 8 pounds this week." B. "I am able to breathe easier today." C. "I cooked dinner last night." D. "There is no swelling in my feet."

Correct Answer is A

Explanation

Choice A reason: A rapid weight gain is a common sign of fluid retention, which can indicate an exacerbation of heart failure.

Choice B reason: Being able to breathe easier would typically indicate an improvement in heart failure symptoms, not an exacerbation.

Choice C reason: Cooking dinner suggests a level of activity that is not indicative of an exacerbation of heart failure.

Choice D reason: The absence of swelling in the feet would generally be a positive sign, not indicative of an exacerbation of heart failure.

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A nurse is contributing to the plan of care for a client who is newly admitted with severe depression. Which of the following actions should be added to the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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