Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Reinforce statements regarding a will to live and realistic plans for the future.

Discuss the client’s suicide plan.

Limit time allowed to play video games.

Encourage the client to discuss thoughts and feelings about wanting to die.

Restrict visitors to family members only.

Answer and Explanation

Correct Answer : A,B,D

Rationale for A: Reinforcing a will to live and encouraging realistic future plans can promote hope and motivation in a depressed adolescent.

Rationale for B: Discussing the client’s suicide plan is essential for assessing risk and ensuring safety. It allows for intervention if the risk is significant.

Rationale for C: While managing screen time can be beneficial, it is less critical than addressing the underlying emotional issues and ensuring safety.

Rationale for D: Encouraging the client to express thoughts and feelings about wanting to die can provide a safe space for the adolescent to discuss suicidal ideation and help the nurse assess risk more effectively.

Rationale for E: Restricting visitors may not be helpful; maintaining social connections can provide support and reduce feelings of isolation.

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Correct Answer is C

Explanation

A. Inquiring about recent stresses is relevant but may not specifically address the emotional state associated with depression.
B. Asking about food preferences is important for a comprehensive assessment but may not be the most direct question for assessing depression.
C. Inquiring about whether the client often feels sad is crucial for assessing the emotional aspect of depression.
D. While changes in sleep patterns are significant, the question about feeling sad directly addresses the emotional component of depression, which is important for a comprehensive assessment.

A. Disrupts group activities. B. Wanders into client’s rooms. C. Talks with nonsensical words. D. Refuses antipsychotic medications.

Correct Answer is B

Explanation

A. Disrupting group activities may be a concerning behavior, but it may not necessarily warrant constant observation.
B. Wandering into client’s rooms poses a safety risk to both the client and others, indicating a need for constant observation to prevent potential harm.
C. Talking with nonsensical words is indicative of disorganized thought processes but may not directly necessitate constant observation for safety.
D. Refusing antipsychotic medications is a concerning behavior, but it alone may not be an immediate safety risk that requires constant observation.

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Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is C

Explanation

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

Correct Answer is B

Explanation

After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

A client with chronic alcohol dependency is admitted due to a recent relapse. Which findings should the nurse expect this client to exhibit? (Select all that apply)

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?