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

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Correct Answer is D

Explanation

D. This statement indicates symptoms of anxiety, which alprazolam is commonly prescribed to alleviate. Alprazolam is a benzodiazepine medication with anxiolytic properties, meaning it helps reduce feelings of anxiety and promote relaxation.

A. This statement suggests the presence of delusional thinking, which is a common symptom of schizophrenia. Alprazolam is not typically indicated for the treatment of delusions associated with schizophrenia.

B. While fatigue may be distressing for the client, it is not an indication for the use of alprazolam. Alprazolam is specifically prescribed for the management of anxiety symptoms.

C. This statement suggests the presence of hallucinations, which are another common symptom of schizophrenia. Alprazolam is not indicated for the treatment of hallucinations associated with schizophrenia.

A. Offer finger foods to the client frequently. B. Weigh client every 3 to 4 days. C. Monitor patient safety throughout the day. D. Maintain an environment with low stimuli. E. Discourage the client from taking a nap during the day.

Correct Answer is ["A","B","D","E"]

Explanation

A. Providing frequent meals and snacks is generally beneficial, it’s essential to focus on nutritious options.

C. Manic episodes can lead to impulsive behavior, increased activity, and risk-taking. Close monitoring ensures early detection of any safety concerns, such as self-harm or aggression.
D. Manic clients are often hypersensitive to stimuli, and a calm, low-stimulation environment can help reduce agitation and prevent exacerbation of symptoms.
E. While adequate rest is essential, discouraging daytime naps may help regulate the client’s sleep patterns and prevent excessive energy levels associated with mania.

B. Regular weight monitoring is essential for assessing overall health, but it may not be a priority specifically related to mania.

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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 schizophrenia and generalized anxiety disorder. The client has a prescription for alprazolam 0.25 mg PO every 8 hr PRN anxiety. For which of the following client statements should the nurse consider administering alprazolam?

Correct Answer is D

Explanation

A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

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