In the treatment of major depressive disorder, why is it important for nurses to regularly assess clients for suicide risk?
It is a part of routine documentation for any disorder.
Regular assessment helps in early identification and prevention of suicidal actions.
Clients with major depressive disorder rarely have suicidal thoughts.
Only post-medication suicide risk is important.
The Correct Answer is B
Choice A reason: While documentation is a professional requirement, the rationale for suicide assessment is primarily clinical safety rather than administrative routine. Reducing the assessment to "routine paperwork" undermines the critical life-saving nature of identifying shifting levels of hopelessness or the development of a specific lethality plan in the client.
Choice B reason: Regular assessment is vital because suicide risk is dynamic and can fluctuate based on internal stressors or treatment changes. Early identification allows the nursing staff to implement life-saving interventions, such as environmental safety checks or increased observation levels, to prevent a tragedy before the client acts on their ideation.
Choice C reason: The statement that clients with major depressive disorder rarely have suicidal thoughts is factually incorrect. Suicidal ideation is a core diagnostic criterion for the disorder. Depression is one of the highest risk factors for completed suicide, making vigilant and frequent assessment a non-negotiable component of psychiatric care.
Choice D reason: While suicide risk can increase when antidepressants provide the energy to act on existing thoughts, the risk is present throughout all phases of the illness. Focusing only on the post-medication period ignores the profound hopelessness experienced during the nadir of a depressive episode when self-harm is also a significant concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A toxicology test, typically performed via urine or blood sampling, is the definitive objective screening tool for identifying the presence of specific chemical metabolites in the body. In an emergency setting, this provides immediate physiological data regarding recent substance ingestion that subjective self-reporting might lack.
Choice B reason: The Eysenick Personality Inventory is a psychological instrument designed to measure specific personality traits, such as extraversion and neuroticism, based on a biopsychosocial model. It is a diagnostic tool for temperament and character assessment and has no utility in detecting the physiological presence of illicit drugs.
Choice C reason: The Personality Diagnostic Questionnaire is a self-report tool used specifically to screen for the presence of personality disorders as defined by the DSM. While the client in the prompt has a personality disorder, this tool assesses long-term behavioral patterns rather than acute substance use or intoxication.
Choice D reason: The Minnesota Multiphasic Personality Inventory (MMPI) is an extensive standardized psychometric test of adult personality and psychopathology. It is used for clinical diagnosis and chronic mental health assessment; however, it is not designed to provide real-time information regarding recent chemical exposure or drug use.
Correct Answer is C
Explanation
Choice A reason: Competitive group activities are highly contraindicated for a client in an acute manic state. Such environments provide excessive stimuli and can trigger agitation, hostility, or physical aggression. Manic clients often have poor impulse control and a low frustration tolerance, making competitive settings unsafe and overwhelming.
Choice B reason: During an acute manic episode, clients experience "flight of ideas" and significant distractibility. Attempting to engage them in complex problem-solving tasks is ineffective and frustrating, as their cognitive processes are too fragmented to maintain the focus required for high-level executive functioning or detailed task completion.
Choice C reason: The priority intervention for acute mania is the reduction of external stimuli to help calm the hyperactive nervous system. A quiet, dimly lit room with minimal noise and activity helps decrease the sensory input that fuels manic behavior, promoting safety and eventually allowing the client to rest.
Choice D reason: While autonomy is a general nursing goal, a client in acute mania lacks the judgment and insight to make safe, independent decisions. Their behavior is often risky, impulsive, and socially inappropriate. Close supervision and set boundaries are necessary to prevent the client from harming themselves or others during this phase.
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