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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. PPD requires timely intervention, and antidepressant medications can be effective in managing symptoms. Anticipating a prescription allows the nurse to prepare for the next steps in the client’s care.
A. While assessing for suicidal or harmful thoughts is essential, it is not the priority in this situation. The client’s symptoms (feeling “down,” sadness, lack of energy, and wanting to cry) are indicative of postpartum depression (PPD), and addressing her emotional well-being is the immediate concern.
C. While coping skills are important, focusing on the family’s coping mechanisms is not the priority at this moment. The client’s individual needs related to PPD take precedence.
D. Although postpartum and newborn care education is essential, it is not the priority when the client is experiencing symptoms of depression. Addressing the client’s emotional state and ensuring appropriate treatment are more urgent.
Correct Answer is ["B"]
Explanation
A. Disordered thinking, also known as formal thought disorder, involves disturbances in the thought process, such as loosening of associations, thought blocking, or tangentiality. These disturbances result in fragmented or illogical thinking patterns.
B. Flat affect refers to a reduction or absence of emotional expression. Individuals with flat affect may appear emotionally dull or unresponsive, showing little variation in facial expressions or vocal tone.
D. Apathy refers to a lack of motivation, interest, or enthusiasm in engaging with one's environment or pursuing goals. Individuals with schizophrenia may experience extreme apathy, which can contribute to social withdrawal and functional impairment.
E. Lack of initiative, also known as avolition, refers to a reduction or absence of goal-directed behavior or motivation to engage in purposeful activities. Individuals with schizophrenia may have difficulty initiating and sustaining activities of daily living or pursuing personal interests.
F. Social withdrawal involves the avoidance or reduction of social interactions and activities. It may result from factors such as social anxiety, apathy, or disinterest in socializing due to psychotic symptoms or negative symptoms of schizophrenia.
C. Trouble concentrating is not typically considered a primary symptom of schizophrenia. While difficulties with concentration or attention may occur, they are more often associated with cognitive impairments rather than positive or negative symptoms.
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