After several days of being despondent and nonverbal, a female client with depression begins to talk and exhibit energy. Which action should the nurse implement?
Involve her in group therapy.
Praise her for the new behavior.
Observe her actions continuously.
Offer her a choice of activities.
The Correct Answer is C
Choice A rationale: Involving her in group therapy may be premature, as the client has just started to exhibit changes in behavior. Continuous observation is necessary to assess the nature and sustainability of these changes.
Choice B rationale: Praising her for the new behavior is positive, but continuous observation is essential to monitor for any signs of escalating or problematic behavior.
Choice C rationale: Observing her actions continuously is the most appropriate action at this point. The nurse needs to monitor the client closely to assess the nature of the changes, ensuring they are not indicative of increased agitation or potential harm.
Choice D rationale: Offering her a choice of activities may be appropriate once the nurse has a better understanding of the clien's current state. However, continuous observation is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: "You may think you are fat, but you look thin to me" is dismissive and may invalidate the client's feelings. It is essential to explore the client's emotions rather than providing a judgmental response.
Choice B rationale: "There are consequences for not eating" is confrontational and may increase the client's anxiety. A more therapeutic approach involves exploring the client's feelings and concerns about eating.
Choice C rationale: "Explain how you feel when it is time to eat" is an open-ended and non-judgmental response. It encourages the client to express her emotions, providing valuable information for further assessment and care planning.
Choice D rationale: "You must eat or you will become very sick" is directive and may increase resistance. It is essential to explore the client's feelings and collaborate on a plan rather than issuing directives.
Correct Answer is D
Explanation
Choice A rationale: Gastric lavage may be considered, but the priority is to address respiratory depression. Naloxone administration is more immediate.
Choice B rationale: Renal dialysis is not indicated for the overdose of methadone and benzodiazepines. Addressing respiratory depression is the priority.
Choice C rationale: Nebulizing with albuterol is not the appropriate intervention for respiratory depression due to drug overdose. Naloxone administration is more critical. Choice D rationale: Administration of naloxone is the priority for this client with respiratory depression due to the potential opioid overdose (methadone). Naloxone is an opioid antagonist that can reverse opioid-induced respiratory depression.
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