An adult client with severe depression was admitted to the psychiatric unit yesterday evening.

Despite having run a marathon a year ago, the client now spends most of the day sitting and watching television, according to the spouse.

What is the most important intervention for the nurse to include in this client’s care plan for today?

Encourage the client to participate in a team sport for one hour.

Assist the client in developing a list of daily affirmations.

Schedule the client for a group session that focuses on self-esteem.

Help the client in identifying goals for the day.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Encouraging the client to participate in a team sport for one hour might be beneficial for the client’s physical health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice B rationale
Assisting the client in developing a list of daily affirmations can be a helpful strategy for improving self-esteem and promoting positive thinking, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice C rationale
Scheduling the client for a group session that focuses on self-esteem can be beneficial for the client’s mental health, but it might not be the most important intervention for a client with severe depression who spends most of the day sitting and watching television.
Choice D rationale
Helping the client in identifying goals for the day can be a very effective intervention for a client with severe depression. Setting daily goals can provide the client with a sense of purpose and can help to motivate the client to engage in activities other than sitting and watching television.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"C,B"},"C":{"answers":"B"}}

Explanation

Choice A rationale

Chronic alcoholism is often associated with both Vitamin B12 and Folic acid deficiency anemia. Alcohol interferes with the absorption of these vitamins in the gut, leading to their deficiency.

Choice B rationale

Malabsorption syndrome can lead to Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. In malabsorption syndrome, the small intestine can’t absorb enough of certain nutrients and fluids.

Choice C rationale

Dietary deficiency can result in Iron deficiency anemia, Vitamin B12 deficiency anemia, and Folic acid deficiency anemia. These types of anemia can occur when the body doesn’t have enough of the vitamins needed to produce enough healthy red blood cells.

A. Determine the presence of ST-elevations or non-ST-elevations on the electrocardiogram B. Initiate dim lighting, lower alarm volumes, and control traffic in and out of the room area C. Verify troponin level assessments are scheduled every 3-6 hours for a series of three D. Apply oxygen via nasal cannula and titrate to keep oxygen saturation above 93%

Correct Answer is D

Explanation

Choice A rationale
Determining the presence of ST-elevations or non-ST-elevations on the electrocardiogram is an important step in diagnosing a myocardial infarction. However, this is typically performed by a healthcare provider or a trained technician, not a nurse.
Choice B rationale
While creating a calm and quiet environment can be beneficial for a client experiencing chest pain, it is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice C rationale
Verifying that troponin level assessments are scheduled every 3-6 hours for a series of three is important for diagnosing myocardial infarction. However, this is not the immediate intervention that should be performed. The client’s symptoms suggest a possible cardiac event, which requires immediate medical intervention.
Choice D rationale
Applying oxygen via nasal cannula and titrating to keep oxygen saturation above 93% is the correct intervention. This action helps to increase the oxygen supply to the myocardium, potentially decreasing the extent of myocardial damage and relieving chest pain.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"C,B"},"C":{"answers":"B"}}

Explanation

Correct Answer is D

Explanation

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