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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choiceB. Confirm that the gown is tied securely at the neck and waist.
Choice A rationale:
Reminding the UAP to wash hands frequently while in the room is important for infection control, but it is not the immediate priority in this scenario. The UAP has already donned gloves, which are part of the personal protective equipment (PPE) required for contact precautions. Hand hygiene is crucial before and after patient contact and after removing gloves, but ensuring the gown is properly secured takes precedence to prevent contamination.
Choice B rationale:
Confirming that the gown is tied securely at the neck and waist is essential to ensure that the UAP is fully protected from potential contamination.A properly secured gown prevents the UAP’s clothing from coming into contact with the patient or contaminated surfaces, which is critical in maintaining effective contact precautions.
Choice C rationale:
Assisting the UAP with the application of a face mask or face shield is necessary for droplet or airborne precautions, not specifically for contact precautions.Since the scenario involves contact precautions, the focus should be on the gown and gloves.
Choice D rationale:
Helping the UAP reposition the gown sleeve over the glove edges is not necessary because the UAP has already secured the tops of the gloves over the gown sleeves.This method is appropriate as it prevents the sleeves from becoming contaminated.
Correct Answer is D
Explanation
Choice A rationale
While it’s important to know the patient’s current medications as they can influence the patient’s condition and treatment plan, this information is not the most critical to convey first in this situation.
Choice B rationale
The increasing confusion of the patient is a significant symptom, especially after a fall. It could indicate a possible head injury. However, the cause of the confusion (the fall) should be communicated first.
Choice C rationale
Knowing who holds the patient’s healthcare power of attorney is important, especially if the patient’s condition worsens and decisions need to be made on their behalf. However, this information is not the most critical to convey first.
Choice D rationale
The fall from a ladder as the reason for admission is the most important information to provide first. This gives the healthcare provider immediate context about the potential severity and type of injuries, guiding further assessment and treatment.
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