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

Answer and Explanation

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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Correct Answer is D

Explanation

A. "Have you thought about taking a sleeping pill?”: While this response acknowledges the client's report of feeling tired, it immediately jumps to suggesting a specific solution without exploring the underlying reasons for the fatigue. It also assumes that medication is the appropriate intervention without further assessment.

B. "Your fatigue will pass, and everything will be just fine.”: This response minimizes the client's concerns and feelings by dismissing them with a vague reassurance. It does not validate the client's experience or offer practical support.

C. "Do you have a family member who can assist you?”: This response acknowledges the client's difficulty with grocery shopping and offers a practical solution by asking about available support from family members. It encourages the client to explore their support system and potential resources.

D. "Let's discuss how to get you the help you need.”: This response demonstrates empathy, validation, and a willingness to collaborate with the client to address their needs. It acknowledges the client's concerns and offers to explore solutions together, empowering the client to be actively involved in their care.

A. Administer a sedative medication. B. Perform a debriefing with the staff. C. Acknowledge the client's emotions D. Place the client in restraints

Correct Answer is C

Explanation

A. Administer a sedative medication: While sedation may be necessary in some cases to manage acute agitation or aggression, it should not be the first action taken. Administration of sedative medication requires a careful assessment of the client's condition, potential drug interactions, and individualized dosing considerations. It's important to consider less restrictive interventions before resorting to sedation.

B. Perform a debriefing with the staff: Debriefing with the staff is an essential step in processing the crisis situation and ensuring the well-being of the team. However, it should not be the first action taken when the client is in immediate danger of harming themselves or others.

C. Acknowledge the client's emotions: Acknowledging the client's emotions and validating their feelings can help establish rapport and de-escalate the situation. However, if the client is actively threatening self-harm or violence, addressing safety concerns should take precedence.

D. Place the client in restraints: Restraints should only be used as a last resort and when less restrictive interventions have failed to ensure the safety of the client and others. Restraints should not be the first action taken, especially if there are other interventions that can be attempted to de-escalate the situation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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