A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

The client assumes an active role in her care planning process.

The client identifies positive qualities about herself.

The client exhibits expected grieving behaviors.

The client makes a contract to avoid self-harm.

Answer and Explanation

The Correct Answer is D

Choice A reason:
While it is beneficial for clients to be involved in their care planning, this is not the immediate priority. Active participation in care planning is a goal that can be pursued once the client's safety and stability are ensured.

Choice B reason:
Identifying positive qualities about oneself is an important step in improving self-esteem and promoting recovery in clients with major depressive disorder. However, this is not the most immediate priority when compared to ensuring the client's safety¹.

Choice C reason:
Exhibiting expected grieving behaviors is a natural and necessary process for healing after the loss of a loved one. However, the priority in the acute phase of care, especially when a client is at risk for self-harm, is to ensure safety.

Choice D reason:
The priority nursing goal for a client with major depressive disorder, especially following a significant loss, is to ensure safety. Making a contract to avoid self-harm is a critical intervention that addresses the risk of suicide, which is heightened in individuals with major depressive disorder and recent significant loss. This contract is a verbal or written agreement between the client and the healthcare provider that the client will not harm themselves and will seek help if they have thoughts of self-harm.

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Correct Answer is B

Explanation

Choice A reason:
Locking the doors and securing windows may prevent an escape attempt, but it does not address immediate risks within the client's environment. It can also make the client feel trapped or punished, which could exacerbate their distress.

Choice B reason:
Removing any objects that could be used for self-harm is a direct intervention that reduces immediate risk. It is a standard safety precaution in managing suicidal clients and helps create a safer environment while further assessments and interventions are planned.

Choice C reason:
Providing plastic eating utensils is a safety measure, but it is not as comprehensive as removing all objects that could be used for self-harm. This action should be part of a broader strategy to ensure safety.

Choice D reason:
Assigning a staff member to stay with the client can provide supervision and prevent an attempt at self-harm. However, it may not be feasible as a long-term solution and does not remove the means for self-harm.

A. The client is seeking sympathy and pity from healthcare providers by feigning illness or injury. B. The client is seeking attention and validation through inducing injury or illness. C. The client's symptoms are the result of a misdiagnosis or medical error. D. The client is seeking financial gain through feigning illness or injury. E. The client is experiencing physical symptoms related to an underlying medical condition.

Correct Answer is ["A","B"]

Explanation

Choice A reason:

This hypothesis aligns with the typical motivations seen in factitious disorder, where individuals intentionally produce or exaggerate symptoms of illness in themselves to receive attention, sympathy, and care from medical personnel¹. The nurse should prioritize understanding this behavior to manage the client's care effectively and to avoid unnecessary medical interventions.

Choice B reason:

Similar to choice A, individuals with factitious disorder may induce injury or illness to fulfill a psychological need for attention and validation. Recognizing this motivation is crucial for the nurse to provide appropriate psychological support and to prevent further self-harm.

Choice C reason:

While misdiagnosis or medical error can occur, this is not typically a hypothesis that should be prioritized in the care of a client with factitious disorder. The disorder involves intentional actions by the client, not errors by healthcare providers.

Choice D reason:

Seeking financial gain is more characteristic of malingering than factitious disorder. In factitious disorder, the primary motivation is psychological gratification from playing the patient role, rather than external incentives like financial gain.

Choice E reason:

Factitious disorder involves the intentional production of symptoms without an underlying medical condition. Therefore, this hypothesis would not be a priority in the care of a client with factitious disorder, as the symptoms are not related to a genuine medical condition but are self-induced.

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A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Correct Answer is B

Explanation

A client presents with symptoms consistent with factitious disorder. Which of the following hypotheses should the nurse prioritize in the care of this client? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

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