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. Barbiturates can cause respiratory depression, hypoventilation, and potentially respiratory arrest, which can lead to hypoxia and cardiac arrest if not promptly recognized and managed.

A. While it's important to assess for any additional drugs or substances that the client may have ingested, this action is not the priority when managing a client with a barbiturate overdose.

B. Seizures can occur as a result of barbiturate overdose, but respiratory depression is the more immediate and life-threatening concern.

C. Ipecac is no longer recommended for the induction of vomiting in cases of drug overdose due to the risk of complications such as aspiration pneumonia and delayed treatment.

A. A child who uses the call light frequently B. A child whose parents answer questions for the child C. A child who has a BMI indicating obesity D. A child who has frequent visitors

Correct Answer is B

Explanation

B. This behavior may be concerning if it indicates a lack of autonomy or control over one's own communication. It could suggest overprotective or controlling behavior by the parents, which may be indicative of emotional abuse or neglect.

A. Frequent use of the call light may indicate a need for assistance or discomfort but does not necessarily indicate abuse. It could be related to the child's medical condition, anxiety, or other factors.

C. Childhood obesity itself is not necessarily indicative of abuse. It can result from a variety of factors, including genetics, dietary habits, and lifestyle factors.

D. Frequent visitors alone do not necessarily indicate abuse. However, it's important to consider the nature of the visitors' relationship with the child and whether they may pose a risk of harm.

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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 client is admitted for a drug overdose with a barbiturate. Which is the priority nursing action when planning care for this client?

Correct Answer is D

Explanation

A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?

Correct Answer is B

Explanation

A nurse is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)

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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 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?

A nurse is assessing a client who has schizophrenia and has been on long-term treatment with chlorpromazine. He notes the client is experiencing some involuntary movements of the tongue and face. The nurse should suspect the client has developed which of the following adverse effects?