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","D"]

Explanation

Choice A reason:
This statement is incorrect. Nausea, vomiting, and diarrhea can be side effects of lithium and are concerns while on this medication. It is important for clients to report these symptoms to their healthcare provider, as they can be signs of lithium toxicity.

Choice B reason:
This statement is correct. Maintaining adequate sodium intake is important while taking lithium. Sodium levels can affect lithium levels in the body, and sudden changes in sodium intake can lead to lithium toxicity or decreased effectiveness of the medication.

Choice C reason:
This statement is incorrect. Lithium does not necessarily need to be taken on an empty stomach. It can be taken with or without food, although taking it with food may help reduce stomach upset.

Choice D reason:
This statement is correct. Regular monitoring of blood levels is essential during the first month of lithium therapy to ensure that lithium levels are within the therapeutic range and to avoid toxicity. The frequency of monitoring may change based on the results and as treatment continues.

A. Give the family an opportunity to talk about their feelings. B. Investigate and identify cues in the client's behavior that might have indicated contemplation of suicide. C. Provide professional counseling for staff members. D. Change policies for staff observation of clients who are suicidal.

Correct Answer is C

Explanation

Choice A reason:
While giving the family an opportunity to talk about their feelings is important, it is not the immediate priority for staff intervention following the incident. The family's needs are crucial, but the question specifically asks about the staff's follow-up actions.

Choice B reason:
Investigating and identifying cues in the client's behavior that might have indicated contemplation of suicide is a critical step in understanding and preventing future incidents. However, this is more of a retrospective action and not the immediate priority for staff intervention after such an event.

Choice C reason:
Providing professional counseling for staff members is the priority intervention. Staff members may experience a range of emotions, including grief, guilt, and trauma, following a client's suicide. Professional counseling can support staff in processing these feelings and prevent potential long-term psychological effects.

Choice D reason:
Changing policies for staff observation of clients who are suicidal may be necessary, but it is not the immediate priority following the incident. Policy review and changes are part of a longer-term strategy to improve care and prevent future incidents.

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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 is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?

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

Explanation

A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff on the unit as a follow-up to this incident?

Correct Answer is C

Explanation

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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?

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