A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?

Ask the client to create her own schedule of daily activities.

Teach the client to use passive communication when interacting with others.

Determine the client's need for assistance with grooming.

Limit the client's involvement in unit activities.

Answer and Explanation

The Correct Answer is C

A. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine.

The other options do not align with best practices for caring for a client with major depressive disorder:

B. Teaching passive communication is not appropriate, as assertive communication is typically encouraged to help the client express her needs and feelings effectively.

C. Asking the client to create their own schedule of daily activities may overwhelm them and exacerbate feelings of hopelessness or indecisiveness commonly experienced with depression. The nurse should provide structure and guidance in establishing a manageable routine

D. Limiting involvement in unit activities could further isolate the client and exacerbate her symptoms. Encouraging participation and engagement is generally more beneficial.

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Correct Answer is A

Explanation

A. "I need to make sure that the potential victim is warned."

Explanation: Correct Answer. When a client threatens to harm a specific individual, it's important to take steps to ensure the safety of both the client and the potential victim. Warning the potential victim or taking appropriate measures to protect them is an important action to take.

B. "I need to keep the information confidential due to the client's right to privacy."

Explanation: While respecting a client's right to privacy is important, when there's a threat of harm to an individual, it becomes a matter of safety that takes precedence over confidentiality.

C. "I can only discuss the client's threats with a court order."

Explanation: This statement is incorrect. When there's a credible threat to harm an individual, waiting for a court order is not an appropriate or timely response. Immediate actions should be taken to ensure safety.

D. "I should verbally report this information to the psychiatrist."

Explanation: While involving the psychiatrist is important for the client's overall care, it's essential to take more immediate steps to ensure the safety of the potential victim, such as notifying the appropriate authorities or taking appropriate precautions.

A. Discuss self-defense techniques with the client. B. Give the client a bed bath prior to physical examination. C. Inform the client photographs of injuries are required for a police report. D. Ask the client to describe the situation.

Correct Answer is D

Explanation

A. Discuss self-defense techniques with the client: Incorrect

While self-defense techniques can be useful information, discussing them immediately after a traumatic event like sexual assault may not be appropriate. The client's immediate needs for emotional support, medical evaluation, and safety are more pressing.

B. Give the client a bed bath prior to physical examination: Incorrect

In cases of sexual assault, preserving evidence is important for legal purposes and for the client's well-being. Providing a bed bath could potentially compromise evidence and hinder a thorough examination by healthcare professionals.

C. Inform the client photographs of injuries are required for a police report: Correct

Preserving evidence is crucial in cases of sexual assault, especially if the client intends to involve law enforcement. Informing the client about the importance of photographs for a police report is appropriate and can contribute to a potential legal investigation.

D. Ask the client to describe the situation: Correct

It's important to encourage the client to share their experience, but it should be done in a sensitive and supportive manner. Gathering information about the situation can help the healthcare team understand the scope of the assault, provide appropriate medical care, and offer necessary emotional support.

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A nurse is planning care for a client newly admitted with major depressive disorder. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

Correct Answer is A

Explanation

A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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