When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

Involve client in daily exercise program.

Ask the client to describe her depression.

Spend time sitting in silence with client.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is C

A.   Involving the client in a daily exercise program may be beneficial for depression but does not directly address the issue of delayed responses during questioning.
B.   Asking the client to describe her depression may be helpful for assessment purposes but does not address the immediate need of dealing with delayed responses.
C.   Spending time sitting in silence with the client allows the nurse to provide a supportive presence without pressure for immediate responses, which can be helpful for a client experiencing depression-related delays in communication.
D.   Observing for signs of possible psychosis is important but may not be indicated solely based on delayed responses; other symptoms would need to be present to warrant this concern.

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Correct Answer is D

Explanation

A. Ineffective community coping may be a concern for a homeless individual but is not the priority in this scenario where the client is disoriented and confused.
B. Disturbed sensory perception typically involves alterations in visual, auditory, tactile, or olfactory senses, which may not be the primary issue in this case.
C. While self-care deficit could be a concern for a homeless individual, it is not the priority when the client is disoriented, disorganized, and confused.
D. Acute confusion is the priority problem because the client is disoriented, disorganized, and confused, indicating a cognitive impairment that needs immediate attention. E. There is no specific rationale provided for this option.

A. Efforts to cut down, annoyance with questions, guilt, drinking as an "Eye-opener." B. Consumption, liver enzyme, gastrointestinal complaints and bleeding. C. Cancer screening results, anger, gastritis, daily alcohol intake. D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.

Correct Answer is A

Explanation

A. The CAGE questionnaire focuses on four key aspects related to alcohol use: efforts to Cut down, Annoyance with questions about drinking, feelings of Guilt about drinking, and using alcohol as an "Eye-opener" in the morning. Exploring these aspects in depth can provide valuable information about the client's relationship with alcohol and potential problems.

B. While information about consumption, liver enzymes, and gastrointestinal complaints is important for assessing alcohol-related issues, these are not specifically addressed by the CAGE questionnaire.
C. Cancer screening results, anger, gastritis, and daily alcohol intake are relevant to assessing the client's overall health and alcohol use but are not directly related to the questions asked in the
CAGE questionnaire.
D. While information about minimizing drinking, missing family events, guilt about drinking, and daily alcohol intake may provide insight into the client's alcohol use, these aspects are not specifically addressed by the questions in the CAGE questionnaire.

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When the nurse addresses questions to an adult client who is depressed, the client's responses are delayed. Which intervention should the nurse include in the client's plan of care?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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