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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.
B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.
C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.
D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.
A. Orthostatic hypotension: Orthostatic hypotension, a sudden drop in blood pressure upon standing up, is a common adverse effect of tricyclic antidepressants. TCAs can block the alpha-1 adrenergic receptors, leading to decreased vascular tone and subsequent orthostatic hypotension.
B. Diarrhea: Diarrhea is not typically associated with tricyclic antidepressants. In fact, constipation is a more common gastrointestinal adverse effect of TCAs due to their anticholinergic properties, which can slow down bowel motility.
C. Hyperactivity: Hyperactivity is not a common adverse effect of tricyclic antidepressants. Instead, TCAs may cause sedation or drowsiness due to their antihistamine properties.
D. Increased urinary output: Tricyclic antidepressants can cause urinary retention rather than increased urinary output. Anticholinergic effects of TCAs can lead to urinary hesitancy, difficulty initiating urination, or retention, particularly in individuals with benign prostatic hyperplasia.
Correct Answer is C
Explanation
A. Voice alteration: Voice alteration is not a typical adverse effect of electroconvulsive therapy (ECT). ECT primarily affects brain function and is not expected to cause changes in vocal function.
B. Neck pain: Neck pain is a potential adverse effect of ECT, particularly related to the positioning of the client during the procedure or muscle stiffness following the seizure induction. It is important to monitor for and address any discomfort or pain experienced by the client.
C. Memory deficit: Memory deficits, particularly short-term memory loss, are common adverse effects of ECT. These deficits are typically temporary and tend to improve over time following completion of the ECT treatment course.
D. Headache: Headache is a potential adverse effect of ECT, particularly following the seizure induction. It may occur due to the physiological effects of the procedure and typically resolves relatively quickly following the completion of the ECT session.
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