An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

"Tell me the reasons you think your mother is depressed."

"Older adults are usually diagnosed with depressive disorder as they age."

"Everyone gets depressed from time to time."

"You shouldn't worry about this, because depressive disorder is easily treated."

Answer and Explanation

The Correct Answer is A

Tell me the reasons you think your mother is depressed. This response shows empathy and active listening and invites the daughter to share more information about her mother's condition and behavior. The other responses are dismissive, inaccurate, or minimizing of the daughter's concern.

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Correct Answer is B

Explanation

Choice A reason:

Obtaining the provider's prescription within 60 min is not the immediate action required in this scenario. The priority is to ensure the safety of the client and others, which is achieved by continuous monitoring and documentation.

Choice B reason:

Documenting the client's behavior every 15 min is crucial in managing physically aggressive clients in seclusion. This allows the healthcare team to monitor the client's condition closely and make necessary interventions promptly.

Choice C reason:

Monitoring the client's vital signs every 4 hr may not be frequent enough for a client in seclusion who has been physically aggressive. The client's condition could change rapidly, and more frequent monitoring might be necessary.

Choice D reason:

Offering food and fluids every 2 hr is important for maintaining the client's physical health, but it is not the primary action in managing a physically aggressive client in seclusion. The immediate focus should be on ensuring safety and managing the client's aggressive behavior.

A. Stop the newly licensed nurse from administering the medication. B. Demonstrate how to verbally de-escalate the situation. C. Discuss the purpose of the medication with the client. D. Assess the need for physical restraints.

Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

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