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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The response, "Lots of people feel ashamed to tell their secrets," is not the most therapeutic option because it does not directly address the client's need to discuss their feelings or concerns. It does offer some empathy but falls short in terms of encouraging communication and understanding.
Choice B rationale:
The response, "You will feel better if you tell me what you did last night," may come across as too direct and pressuring, which can be counterproductive in building trust with the client. It may make the client feel even more embarrassed or uncomfortable.
Choice D rationale:
The response, "You shouldn't feel embarrassed to talk to me," attempts to reassure the client but may invalidate their feelings and is not as therapeutic as the correct choice. It's important to acknowledge the client's emotions and provide them with a safe space to open up.
Correct Answer is C
Explanation
A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization? The correct answer is Choice C: A client who states she did not get a promotion because her boss dislikes her.
Choice A rationale:
Choice A, a client who states she will worry about her grades after she finishes planning a party, represents the defense mechanism of "intellectualization" rather than rationalization. Intellectualization is when an individual uses excessive reasoning and logic to distance themselves from emotional reactions.
Choice B rationale:
Choice B, a client whose partner died 5 years ago still talks about him in the present tense, represents "denial" rather than rationalization. Denial involves refusing to accept the reality of a situation or a feeling.
Choice C rationale:
Rationalization is a defense mechanism in which a person provides logical-sounding explanations to justify or make excuses for their behavior or actions. Choice C, a client who attributes not getting a promotion to their boss disliking them, exemplifies rationalization as the client is creating a seemingly plausible reason for the situation rather than accepting their role in not receiving the promotion.
Choice D rationale:
Choice D, a client who has stomach pain before presenting a project to his coworkers, represents "somatization" rather than rationalization. Somatization is a defense mechanism where emotional distress is expressed as physical symptoms.
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