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 C

Explanation

A. Remain 15 cm (6 in) away from the client: Maintaining a safe physical distance is important to ensure the safety of both the client and the staff member. However, the specific distance may vary depending on the situation and the client's level of agitation. It's essential to maintain a safe distance while still engaging with the client in a supportive manner.

B. Use a raised voice when speaking to the client: Using a raised voice can escalate the situation further and may increase the client's agitation or aggression. It's important to speak calmly and softly to avoid escalating the situation.

C. Determine the cause of the client's feelings: Understanding the underlying reasons for the client's aggression can help the nurse address the root cause and implement appropriate interventions. It's important to listen actively to the client, validate their feelings, and demonstrate empathy.

D. Ask the client short close-ended questions: Close-ended questions typically elicit simple "yes" or "no" responses and may not encourage open communication or help the client express their feelings. Instead, it's more beneficial to ask open-ended questions that allow the client to express themselves and feel heard.

A. The client states that he has developed sudden hearing loss B. The client states that his partner will not visit because they are too busy with their job C. The client yells obscenities at the nurse D. The client stomps his fees and throws objects of the bedside table

Correct Answer is D

Explanation

A. The client states that he has developed sudden hearing loss: This could potentially be an example of somatization, where psychological distress is expressed through physical symptoms. However, sudden hearing loss alone might not specifically indicate regression.

B. The client states that his partner will not visit because they are too busy with their job: This statement does not directly suggest regression. It appears to be an explanation or justification for the partner's behavior.

C. The client yells obscenities at the nurse: Yelling obscenities could indicate frustration or anger, but it does not necessarily suggest regression. It could be a response to the current situation rather than a regressive behavior.

D. The client stomps his feet and throws objects off the bedside table: This behavior could indicate regression. Stomping feet and throwing objects are more characteristic of childish or immature behavior, which suggests a regression to an earlier stage of emotional development.

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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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Correct Answer is C

Explanation

Correct Answer is D

Explanation

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