A nurse is planning care for a client who has major depressive disorder and is being admitted following a suicide attempt. Which of the following interventions is the nurse's priority?
Initiate one-to-one observation.
Encourage the client to participate in group activities
Administer an antidepressant
Set up a time for individual meetings with the client
The Correct Answer is A
A. Initiate one-to-one observation: This intervention involves assigning a staff member to directly observe and monitor the client continuously. It is crucial in ensuring the client's safety, particularly after a suicide attempt, as it helps prevent further harm or self-injury. Therefore, initiating one-to-one observation is the priority intervention.
B. Encourage the client to participate in group activities: Group activities may be beneficial for the client's overall well-being and recovery, but they are not the priority immediately after a suicide attempt. Safety and stabilization take precedence.
C. Administer an antidepressant: While antidepressant medication is an essential component of treatment for major depressive disorder, initiating medication is not the priority at this moment. The client's safety and stabilization should be addressed first before starting pharmacological treatment.
D. Set up a time for individual meetings with the client: Individual meetings and therapeutic interventions are important for addressing the client's mental health needs, but they are not the priority immediately after a suicide attempt. Safety measures should be implemented first.
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Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Grandiosity: Individuals experiencing a manic episode may exhibit grandiosity, such as an inflated sense of self-importance, superiority, or power.
B. Flight of ideas: Flight of ideas refers to rapid, continuous speech that jumps from one topic to another, often with loose associations. It is a common manifestation of a manic episode.
C. Splitting: Splitting is a defense mechanism commonly associated with certain personality disorders, such as borderline personality disorder, but it is not typically observed during a manic episode of bipolar disorder.
D. Hyperactivity: Hyperactivity, or increased physical activity, is characteristic of a manic episode. Clients may engage in excessive goal-directed activities or restlessness.
E. Withdrawal: Withdrawal, or social withdrawal, is not a typical behavior during a manic episode. Instead, individuals with mania tend to exhibit increased sociability and extroversion.
Correct Answer is A
Explanation
A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.
B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.
C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.
D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.
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