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 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.

A. Talk to the client and identify the specific limits that are required of the client's behavior. B. Escort the client to her room each time the nurse observes the client socializing with other clients. C. Discuss the problem in a community meeting with the other clients on the unit present. D. Tell the other clients to ignore the client's lies.

Correct Answer is A

Explanation

A. Engaging in a conversation with the client allows the nurse to set clear expectations and boundaries. The nurse can explain the acceptable behavior and the consequences of disruptive actions. It’s essential to approach this conversation calmly and professionally.

B. While removing the client from social situations may temporarily prevent disruptive behavior, it does not address the underlying issue. Isolating the client may also negatively impact their well- being. It’s better to address the behavior directly rather than resorting to isolation.

C. Holding a community meeting involving all clients may not be appropriate or effective. It could escalate tensions and create an uncomfortable environment for everyone. Individualized interventions are more effective.

D. Ignoring disruptive behavior may not be the best approach. It’s essential to address the issue directly rather than expecting other clients to tolerate disruptive behavior.

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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

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 hospitalized client who tells lies about other clients. The other clients on the unit frequently complain to the nursing staff about the client's disruptive behaviors. Which of the following initial actions should the nurse take?

Correct Answer is A

Explanation

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