The night nurse reports that the client, who is hospitalized with major depressive disorder, has been unable to sleep until late at night.

The client gets up, paces the hallway, wrings their hands, and appears teary.

Which interventions should the nurse advocate to add to the care plan? Select all that apply.

Choice A rationale
This response encourages the patient to express their feelings and promotes open communication. It is a therapeutic communication technique.
Choice B rationale
This response shows empathy and validates the patient’s feelings. It is a therapeutic communication technique.
Choice C rationale
This response could obstruct effective communication as it tells the patient what they should do. It does not encourage the patient to express their feelings or promote open communication.
Choice D rationale
This response could obstruct effective communication as it offers false reassurance. It does not acknowledge the patient’s feelings or concerns.

Choice A rationale
Suicidal ideations are a critical concern in individuals who have recently experienced a significant loss and are exhibiting symptoms of depression, such as memory loss, insomnia, loss of appetite, and irritability. The loss of a spouse can trigger intense grief, which can lead to physical and mental health issues, including sleep disorders like insomnia, and loss of appetite. In severe cases, the individual may also experience a heart attack. Therefore, assessing for suicidal ideations is crucial in these situations.
Choice B rationale
While a medication history is important in any health assessment, it is not the most critical data to obtain in this specific scenario. The client’s symptoms are more indicative of a grief reaction or possible depression, which would not be directly revealed through a medication history.
Choice C rationale
Although alcohol use can exacerbate symptoms of depression and grief, and it is important to assess alcohol use in any patient presenting with mental health concerns, it is not the most critical data to obtain in this scenario. The client’s symptoms and recent loss point more towards a need to assess for suicidal ideations.
Choice D rationale
Anhedonia, or the inability to feel pleasure, is a common symptom of depression. However, in this scenario, the client’s symptoms and recent loss make it more critical to first assess for suicidal ideations.