An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Monitor food intake and eliminate potential sources of tyramine.

Assess for weight loss and difficulty sleeping.

Monitor the client for migraines.

Implement suicide precautions.

Answer and Explanation

The Correct Answer is D

D. Children and adolescents with depression, especially when initiating or adjusting antidepressant medications like SSRIs, are at an increased risk of suicidal ideation and behavior. Therefore, it is crucial to prioritize the safety of the client by implementing suicide precautions, which may include close observation, removing potential means of self-harm, and involving the client in structured activities under supervision.

A. Monitoring food intake and eliminating potential sources of tyramine are considerations for clients taking monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, due to the risk of hypertensive crisis.

B. Weight loss and difficulty sleeping are potential side effects of SSRIs that may occur, particularly during the initial phases of treatment. However, suicide precautions are a priority

C. While SSRIs may cause headaches or migraines as potential side effects, monitoring for migraines specifically would not typically be a priority

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

C. Acknowledging the client’s feelings while normalizing them can help reduce the sense of isolation and

provide validation. It’s essential to maintain empathy and avoid dismissing the client’s emotions.

A. While this response acknowledges the client’s feelings, it may come across as confrontational or probing. It’s essential to approach the conversation with empathy and avoid putting the client on the defensive.

B. This response reflects understanding and empathy. However, it does not directly address the client’s

statement about worthlessness.

D. It’s essential to avoid making assumptions about what the client values or finds meaningful. Focusing on empathy and understanding is more effective.

A. The child has a preference for associating with peers, rather than adults. B. The child has learning problems and shyness. C. The child tells sexually explicit stories to peers. D. The child wears dirty and threadbare clothing.

Correct Answer is C

Explanation

C. The child telling sexually explicit stories to peers could be concerning and warrants further investigation. A child speaking in this manner could indicate that they are frequently expose to sexual content of abuse
A. The child has a preference for associating with peers, rather than adults. While this may need further assessment, it does not necessarily point to sexual abuse.
B. Learning problems and shyness alone are not specific indicators of sexual abuse.

D. While poor hygiene and clothing conditions can be signs of neglect, they are not directly related to sexual abuse. Poor hygiene and clothing is more likely to point to child neglect.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

An 11-year-old client has been hospitalized on the adolescent psychiatry unit with severe depression. For the past several weeks, the client has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse. "I should have died because I am totally worthless." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

Which behavior would first alert the school nurse or teacher to suspect sexual abuse in a 7-year- old child?

Correct Answer is C

Explanation

A nurse is caring for a client who has obsessive-compulsive disorder (OCD). Which of the following characteristics are expected findings of OCD? (Select all that apply.)

The nurse is doing an admission assessment on a client with schizophrenia. Which of the following are positive symptoms of schizophrenia?

Which are common reasons why abused persons remain with an abusive partner? Select all that apply.

A nurse is planning care for a client who is in the manic phase of bipolar disorder. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?

A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting. and now the client is pacing up and down the corridors of the unit. Which of the following actions should the nurse take?