A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Instruct family to avoid visiting during mealtimes.

Give the client extra time to communicate needs.

Offer three or four large meals daily.

Discourage rest periods during the daytime.

Answer and Explanation

The Correct Answer is B

Clients with depression may experience cognitive difficulties, such as trouble concentrating or articulating their needs. Giving the client extra time to express themselves and communicate their needs allows them to feel heard and understood. It also helps establish a therapeutic relationship with the client, promoting trust and collaboration in their care.

The other interventions listed may not be appropriate or effective in addressing the client's specific symptoms of depression:

A- Instructing the family to avoid visiting during mealtimes may not be necessary unless there are specific reasons related to the client's preferences or distractions during meals. It's important to involve the family in the client's care and support, including mealtime interactions, unless there are specific concerns or circumstances.

C- Offering three or four large meals daily may not be appropriate for all clients with depression. Some individuals may have a decreased appetite or experience changes in their eating patterns. It is important to assess the client's nutritional needs and preferences and provide a balanced meal plan tailored to their specific situation.

D- Discouraging rest periods during the daytime may not be helpful, as individuals with depression may experience fatigue, lack of energy, and a desire to sleep more. Adequate rest and sleep are important for overall well-being, and it is crucial to support the client in maintaining a regular sleep schedule and addressing any sleep disturbances they may be experiencing.

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Correct Answer is A

Explanation

Anxiety and diaphoresis: Alcohol withdrawal commonly presents with symptoms of anxiety, restlessness, and excessive sweating (diaphoresis). These symptoms are due to the central nervous system's hyperactivity caused by the sudden cessation of alcohol intake.

Incorrect:

B- Muscle aches and chills: Muscle aches and chills are not typical manifestations of alcohol withdrawal. These symptoms are more commonly associated with opioid withdrawal rather than alcohol withdrawal.

C- Fatigue and depression: Fatigue and depression are common symptoms during alcohol withdrawal. The client may feel tired, lack energy, and experience a low mood due to the neurochemical imbalances that occur during withdrawal.

D- Arrhythmia and respiratory depression: While alcohol withdrawal can lead to some cardiovascular and respiratory symptoms, such as increased heart rate and blood pressure, severe arrhythmia and respiratory depression are not typical findings. These more severe symptoms may indicate a more severe withdrawal syndrome or coexisting medical conditions that require immediate medical attention.

A. Have the client join a therapy group. B. Suggest that the client rest in bed. C. Remain with the client for a while. D. Medicate the client with a sedative.

Correct Answer is C

Explanation

Remaining with the client provides them with a sense of security, reassurance, and support. It shows the client that they are not alone and that the nurse is there to provide assistance and care. By being present and offering a calming presence, the nurse can help the client feel more at ease and gradually reduce their anxiety.

It's important to note that the other options are not the most appropriate actions in this situation:

A- Having the client join a therapy group may be overwhelming and may not be suitable during the acute phase of panic-level anxiety.

B- Suggesting that the client rest in bed may not address their immediate anxiety and may not be feasible if the client is experiencing intense anxiety symptoms.

D- Medicating the client with a sedative should be done based on a healthcare provider's order and assessment of the client's condition. It is not the initial therapeutic intervention and should only be considered if other non-medication interventions are ineffective or if the client's anxiety becomes severe and unmanageable.

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A nurse is planning care for a client who has depression. The nurse notes that the client has weight loss, an inability to concentrate, an inability to complete everyday tasks, and a preference to sleep all day. Which of the following interventions should be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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