A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder.
Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

Significant weight loss.

Markedly neglected hygiene.

Poor problem-solving skills.

Psychomotor retardation.

Answer and Explanation

The Correct Answer is D

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines? The correct answer is Choice D: Psychomotor retardation.

Choice A rationale:

Significant weight loss may be a concerning symptom in a client with major depressive disorder, but it is not the top priority. Major depressive disorder can lead to changes in appetite, which may result in weight loss. However, psychomotor retardation, which is a significant slowing of physical and mental activities, is a more critical finding. It can be a sign of severe depression and even potential suicidal ideation. Reporting psychomotor retardation to other disciplines allows for a prompt evaluation of the client's safety.

Choice B rationale:

Markedly neglected hygiene is an important observation and may indicate the client's inability to perform self-care activities. While this should be addressed, psychomotor retardation takes precedence as it can indicate more severe symptoms associated with major depressive disorder.

Choice C rationale:

Poor problem-solving skills are a common cognitive symptom of major depressive disorder, but they are not an immediate priority. Clients with depression often struggle with decision-making and problem-solving, but psychomotor retardation is a more severe and concerning symptom that warrants immediate attention.

Choice D rationale:

Psychomotor retardation is the top priority finding in this scenario. It can be a sign of severe depression and may be associated with an increased risk of self-harm or suicide. Reporting psychomotor retardation allows the interprofessional team to assess the client's safety and initiate appropriate interventions promptly.

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Correct Answer is D

Explanation

The most important action for the nurse to take first is to establish a rapport and foster trust with the client. This is represented by option d.

Here's why the other options are not the best first steps:

a. Implement continuous one-to-one observation:While monitoring safety is crucial,it does not address the immediate emotional need of the client,who has just endured a traumatic experience.Building trust first can facilitate open communication and help the client feel safe enough to express their feelings and needs.
b. Ask the client to sign a no-suicide contract:No-suicide contracts have limited effectiveness and can even be harmful by putting undue pressure on the client.Building trust and a collaborative plan are more effective ways to manage safety.
c. Encourage the client to participate in group therapy:Group therapy can be beneficial,but it's not appropriate as the immediate first step.Individualized attention and establishing a secure relationship are crucial at this early stage.

Therefore, establishing rapport and fostering trust is the most important action for the nurse to take first. This will create a safe space for the client to openly express their thoughts and feelings, allowing the nurse to assess their needs and develop a proper care plan.

Remember, this is just the first step. Subsequent actions will involve a comprehensive assessment, safety measures, and collaborating with the client and other healthcare professionals to develop a personalized treatment plan.

A. Withhold the next dose of the medication. B. Ask the client about a recent change in laundry detergent. C. Apply hydrocortisone cream on the client's rash. D. Explain that the medication causes a temporary rash.

Correct Answer is A

Explanation

The correct answer is: A. Withhold the next dose of the medication.

Choice A rationale: Lamotrigine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Any rash should be taken seriously, and the medication should be withheld immediately to prevent potential severe reactions1.

Choice B rationale: While a change in laundry detergent could cause a rash, it is less likely to be the cause if the rash appeared after starting lamotrigine.

Choice C rationale: Applying hydrocortisone cream may help with mild skin irritations, but it does not address the potential severity of a drug-induced rash.

Choice D rationale: Explaining that the medication causes a temporary rash is not appropriate without first assessing the severity of the rash and withholding the medication.

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A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder.
Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?