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 D

Explanation

A. While choice A, “I haven’t gotten my period yet, and all my friends have theirs,” is a valid concern for a 13-year-old, it is generally a normal part of development. Menarche can occur anywhere between ages 9 and 16, so it’s not uncommon for some girls to start later than their peers. However, it is important to address this concern and provide reassurance.

B- "My parents treat me like a baby sometimes." This comment suggests a possible issue with parent-child dynamics, but it does not indicate an immediate health concern. The nurse may explore this further during a counseling session or refer the adolescent to a school counselor if necessary.

C- "There's a big pimple on my face, and I worry that everyone will notice it." While acne can impact an adolescent's self-esteem, it is not a priority issue from a health perspective. The nurse can provide support, discuss basic skincare practices, and offer guidance on managing acne if appropriate.

D. "None of the kids at this school like me, and I don't like them either." This comment indicates potential issues with social relationships, isolation, and possible mental health concerns, which should be prioritized for further evaluation and support. The client might be at risk for depression, an eating disorder or self-harm.

A. "Why are you feeling so down?" B. "It might help you feel better if you talk about it." C. "I understand. I've felt like that before, too." D. "I'll just sit here with you for a few minutes then."

Correct Answer is D

Explanation

This response acknowledges the client's feelings and respects their desire for space and silence. By offering to sit with the client, the nurse provides a comforting presence without pressuring the client to talk or share their emotions. It shows understanding and support for the client's current emotional state.

The other options may not be as helpful in this situation:

A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.

B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.

C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.

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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

A school nurse is talking with a 13-year-old female at her annual health-screening visit. Which of the following comments made by the adolescent should be the nurse's priority to address?

Correct Answer is D

Explanation

A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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