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

Spend time sitting in silence with the client.

Involve the client in a daily exercise program.

Ask the client to describe her depression.

Observe for signs of possible psychosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Spending time sitting in silence with the client can be a therapeutic intervention for someone who is depressed and experiencing delayed responses. It allows the client to feel a sense of presence and support without the pressure to speak or respond immediately.
This approach can help create a safe and non-judgmental environment for the client to express themselves when they are ready.

Choice B rationale:
Involving the client in a daily exercise program may be a beneficial part of the overall care plan for managing depression, but it does not directly address the client's delayed responses during interactions.

Choice C rationale:
Asking the client to describe her depression may be a useful therapeutic intervention to explore the client's feelings and experiences, but it should be done in a way that respects the client's pace and readiness to discuss her emotions.

Choice D rationale:
Observing for signs of possible psychosis is important for assessing the client's mental health, but delayed responses alone may not necessarily indicate psychosis. It's essential to consider the broader clinical picture and conduct a comprehensive assessment.

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Correct Answer is A

Explanation

Choice A rationale:
Assisting the client with relaxation techniques within the group is an appropriate and immediate intervention for managing severe anxiety. This approach can help the client regulate their anxiety levels and provide a sense of support in the therapeutic environment.

Choice B rationale:
Escorting the client from the group to reduce stimuli may be considered if the client's anxiety becomes overwhelming and they cannot manage it within the group setting. However, it is generally preferable to try in-group interventions first.

Choice C rationale:
Providing education about ways to cope with anxiety is valuable, but it may not be the most effective intervention in the moment when the client is already experiencing severe anxiety. Practical techniques should be initiated first.

Choice D rationale:
Asking the client to describe and identify the source of the feelings may be a useful therapeutic technique in individual therapy sessions but may not be the best immediate intervention during a group therapy session when the focus is on managing acute anxiety.

A. Any history of heart disease. B. Familial history of mental illness. C. Current weight. D. Medication history.

Correct Answer is D

Explanation

A. Any history of heart disease: While a history of heart disease is important for general health, it is not the most critical factor prior to initiating sertraline. The nurse should still assess for cardiovascular conditions, but this is not the most pressing concern.

B. Familial history of mental illness: While a familial history of mental illness can inform treatment decisions, it is not the most immediate or critical piece of information before starting sertraline.

C. Current weight: Weight is generally not the primary consideration before starting sertraline. However, weight changes can occur during treatment, but this is more of a concern during the ongoing management of the medication.

D. Medication history: Sertraline, as a selective serotonin reuptake inhibitor (SSRI), can interact with other medications, especially those affecting serotonin levels (e.g., other antidepressants, MAO inhibitors, etc.). It is crucial to assess the client’s current medication history to prevent harmful drug interactions, such as serotonin syndrome. This is the most important information to gather before initiating treatment.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Correct Answer is A

Explanation

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse determines the plan of care. For each action, click to indicate whether they would be included or not included in the plan of care for the client. Each row must have only one response option selected. Actions

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, "What took you so long to get in here!" Which action should the nurse implement?

Patient Data History and Physical Exhibits here What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

The nurse is developing a plan of care for an older client with hypertension who reports chest pain on exertion. Which outcome should the nurse include in the plan of care for this client?