A patient diagnosed with major depression has lost 9 kilograms in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention has the highest priority?
Implement suicide precautions
Recommend group therapy for the patient
Observe patient for therapeutic effects of antidepressant medication
Offer high-calorie snacks and fluids frequently
The Correct Answer is A
Choice A reason: The presence of a specific suicide plan in a patient with major depression constitutes a psychiatric emergency. Safety is always the highest priority in the hierarchy of needs. The nurse must establish 1:1 observation or suicide or constant visual monitoring to prevent self-harm, as the patient’s intent and plan indicate an immediate threat to life.
Choice B reason: While group therapy is an effective evidence-based intervention for addressing chronic low self-esteem and social isolation in depressed patients, it is not a priority during an acute suicidal crisis. The patient must be stabilized and safe before they can meaningfully participate in or benefit from the interpersonal dynamics of a therapeutic group setting.
Choice C reason: Observing for therapeutic effects is important, but antidepressants typically require 2 to 4 weeks to show significant clinical improvement. At 1 week, the patient remains highly symptomatic and may even experience a "wash-in" period where energy increases slightly while suicidal ideation remains high, actually increasing the immediate risk of a suicide attempt.
Choice D reason: A weight loss of 9 kilograms in 1 month is significant and requires nutritional intervention like high-calorie snacks. However, nutritional status is secondary to immediate physical safety. Physical survival from a suicide attempt takes precedence over correcting nutritional deficits, although both will eventually be addressed in the comprehensive multidisciplinary plan of care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The registered nurse holds the ultimate legal and professional accountability for the patient's safety and the ongoing monitoring of restrained individuals. This includes regular assessment of neurovascular status, skin integrity, and the continued necessity of the restraint, regardless of who physically applied the device or who ordered it.
Choice B reason: Unlicensed assistive personnel (UAP) may assist in the application of restraints under the direction of a nurse, but they do not hold the professional responsibility for the clinical decision-making or the comprehensive safety assessments required by hospital policy and legal standards of care.
Choice C reason: While the health care provider (physician or NP) is responsible for providing the legal order and justifying the medical necessity of the restraint, they are not present for the continuous bedside monitoring. The provider relies on the nursing staff to ensure safe implementation and monitoring.
Choice D reason: Family members may provide consent for a treatment plan, but they have no professional or legal responsibility for the patient's physical safety or the clinical management of restraints. Responsibility for safety cannot be delegated to non-medical personnel or family members in a clinical setting.
Correct Answer is D
Explanation
Choice A reason: Detachment and overconfidence are behaviors more commonly associated with personality traits or certain phases of a manic episode. They do not typically indicate the presence of internal stimuli or hallucinations, which generally cause the patient to appear distracted or engaged with something the nurse cannot see or hear.
Choice B reason: Foot tapping is a sign of anxiety or motor restlessness (akathisia), and repeatedly writing the same phrase (graphorrhea) can be a sign of obsessive-compulsive behavior or a formal thought disorder. While these are significant psychiatric findings, they are not standard "listening behaviors" that suggest the patient is hearing voices.
Choice C reason: Euphoric mood, hyperactivity, and distractibility are the classic symptoms of a manic episode in bipolar disorder. While a manic patient might experience hallucinations, these specific symptoms describe a state of elevated mood and energy rather than the specific behavioral cues that a patient is currently experiencing auditory hallucinations.
Choice D reason: These are the classic "listening behaviors" indicative of auditory hallucinations. Darting eyes suggest the patient is looking for the source of a sound; a tilted head suggests they are straining to hear a voice; and mumbling indicates they may be responding to or "talking back" to the internal voices they are hearing.
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