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 D

Explanation

Choice A reason:
Identifying the client's support systems is an important aspect of the assessment, as support systems can play a crucial role in the client's recovery. However, it is not the highest priority during the initial assessment. Support systems can provide emotional, social, and sometimes financial assistance, which can be beneficial in managing a situational crisis.

Choice B reason:
Identifying the client's coping skills is also important because it helps the nurse understand how the client typically deals with stress and crises. Coping skills are mechanisms that individuals use to manage stressful situations and can include problem-solving, seeking support, and using relaxation techniques. However, this is not the highest priority during the initial assessment.

Choice C reason:
Asking the client to identify the cause of the crisis can provide valuable information about the client's perspective and insight into the situation. Understanding the cause can help in planning appropriate interventions. However, this is not the highest priority during the initial assessment, especially if the client is not in a stable condition to discuss the crisis.

Choice D reason:
Determining if the client has psychotic thinking, is the highest priority. Psychotic thinking can include delusions, hallucinations, and disorganized thoughts, which may indicate a severe mental health condition that requires immediate attention. It is essential to assess for psychotic symptoms to ensure the safety of the client and others, as well as to determine the need for urgent psychiatric intervention.

A. Increased heart rate B. Slow, shallow breathing C. Constricted pupils D. Increased motor activity

Correct Answer is B

Explanation

Choice A reason:
Increased heart rate is not typically a sign of opioid overdose. Opioid overdose often leads to a decrease in the body's autonomic responses, which can cause a slowing of the heart rate rather than an increase.

Choice B reason:
Slow, shallow breathing is a hallmark sign of opioid overdose. Opioids can depress the central nervous system, leading to respiratory depression. This is a critical symptom and requires immediate medical attention¹²³⁴.

Choice C reason:
Constricted pupils, also known as pinpoint pupils, are another classic sign of opioid overdose. This occurs due to the action of opioids on the part of the brain that regulates the size of the pupils¹²³⁴.

Choice D reason:
Increased motor activity is generally not associated with opioid overdose. Instead, opioids tend to cause a decrease in motor activity, leading to lethargy and a lack of coordination.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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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