A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

Seasonal affective disorder

Persistent depressive disorder

Major depressive disorder

Premenstrual dysphoric disorder

Answer and Explanation

The Correct Answer is C

A. Seasonal affective disorder (SAD): While individuals with SAD experience depressive symptoms that tend to occur seasonally, typically in the winter months, the severity of symptoms is generally less severe compared to MDD. While suicide risk can still be present in individuals with SAD, it is usually lower compared to those with MDD.

B. Persistent depressive disorder (PDD): Persistent depressive disorder, formerly known as dysthymia, is characterized by chronic depressive symptoms that are less severe than those seen in MDD. While individuals with PDD may experience prolonged feelings of sadness and hopelessness, their symptoms may not reach the severity seen in MDD. Therefore, the risk of suicide may be lower in individuals with PDD compared to those with MDD.

C. Major depressive disorder (MDD): Major depressive disorder is characterized by persistent feelings of sadness, hopelessness, and worthlessness, along with a loss of interest or pleasure in activities. Individuals with MDD are at significant risk of suicide, especially if their depressive symptoms are severe. The presence of traction may exacerbate feelings of hopelessness or helplessness in individuals with MDD, further increasing the risk of suicide.

D. Premenstrual dysphoric disorder (PMDD): PMDD is a severe form of premenstrual syndrome (PMS) characterized by significant mood disturbances and other symptoms that occur in the luteal phase of the menstrual cycle. While PMDD can cause distressing symptoms, including depressive mood, irritability, and anxiety, it is typically limited to the premenstrual period and does not carry the same chronicity or severity as MDD. Therefore, the risk of suicide may be lower in individuals with PMDD compared to those with MDD.

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Correct Answer is D

Explanation

A. Skin integrity: Skin integrity can be an indicator of dehydration, as dehydrated skin may appear dry and lack elasticity. However, skin turgor is not the most reliable indicator of fluid loss because it can be influenced by factors such as age and overall health. For example, infants and older adults may have decreased skin turgor due to a loss of skin elasticity, even if they are adequately hydrated.

B. Blood pressure: Blood pressure can decrease with significant fluid loss because there is less fluid volume to fill the arteries, leading to a drop in blood pressure. However, blood pressure is not the most reliable indicator of fluid loss because it can be influenced by many other factors, such as heart function and vascular resistance. Additionally, blood pressure may not change significantly until severe dehydration occurs.

C. Respiratory rate: An increased respiratory rate can be a sign of dehydration because the body may try to compensate for fluid loss by increasing the respiratory rate to deliver more oxygen to the tissues. However, an increased respiratory rate is a nonspecific symptom that can be associated with many other conditions, such as fever, pain, or lung disease. Therefore, it is not the most reliable indicator of fluid loss.

D. Body weight: Body weight is the most reliable indicator of fluid loss. This is because water makes up a significant portion of body weight, so a decrease in body weight is a direct indication of fluid loss. In infants, a rapid change in weight is often the first sign of fluid imbalance because they have a higher percentage of body water and a higher metabolic rate compared to adults. A 5% weight loss is considered mild dehydration, 10% is moderate, and 15% or more is severe. Therefore, regular monitoring of an infant’s weight is crucial when assessing for dehydration.

A. Restrain the child physically. B. Ignore the temper tantrums. C. Distract the child by offering to play a game. D. Tell the child that temper tantrums are not acceptable

Correct Answer is C

Explanation

A. Restrain the child physically: Physically restraining a toddler during a temper tantrum can escalate the situation and may lead to the child feeling scared or more frustrated. It's important to avoid physical force as it can be traumatic for the child and potentially harmful.

B. Ignore the temper tantrums: Ignoring temper tantrums might work in some situations, but it's not always the most effective strategy. Toddlers often tantrum to seek attention or express frustration, and ignoring them entirely may not address the underlying issue. Additionally, consistent ignoring can lead to feelings of abandonment or exacerbate the behavior.

C. Distract the child by offering to play a game: Distraction can be an effective technique for managing temper tantrums in toddlers. Offering to engage the child in a fun activity or game can redirect their focus away from the source of frustration, helping to de-escalate the situation and promote positive behavior.

D. Tell the child that temper tantrums are not acceptable: While it's important to set boundaries and teach appropriate behavior, telling a toddler that temper tantrums are not acceptable may not effectively address the immediate situation. Toddlers may not fully understand or be able to control their emotions, so simply telling them that tantrums are unacceptable without providing alternative coping strategies is unlikely to be effective.

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A nurse on a mental health unit is caring for clients who have various d Bryant traction. When determining that the traction is the following client diagnoses as presenting the greatest risk for suicide?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent?

Correct Answer is C

Explanation

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