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. While sleep deprivation is a concern, the client's impulsive behavior poses a greater immediate risk, making "Risk for self-directed violence related to impulsive behavior" the priority.
B. Ineffective coping may be a contributing factor, but the risk of self-directed violence takes precedence as the primary concern.
C. The client's impulsive behavior increases the risk of self-directed violence, making it the most urgent nursing priority.
D. Imbalanced nutrition is a concern, but the immediate risk of self-directed violence requires more immediate attention.

A. Family history of dementia. B. Witness to an accident. C. Alcohol use. D. Inadequate diversional activity.

Correct Answer is C

Explanation

A. A family history of dementia may be relevant but is not typically associated with violent nightmares. Alcohol use is more directly related to this symptom.
B. Witness to an accident may be a traumatic experience, but it does not specifically address the symptom of violent nightmares.
C. Alcohol use can contribute to sleep disturbances, including nightmares. Exploring the client's alcohol use is essential in understanding the cause of the nightmares.
D. Inadequate diversional activity is a broad concept and may not be directly related to the specific symptom of violent nightmares.

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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

Correct Answer is C

Explanation

The nurse assesses a client who recently began experiencing violent nightmares. Which factor in the client’s history should the nurse further explore?

Correct Answer is C

Explanation

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)

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