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A client has just been diagnosed as having major depression. At which time would the nurse expect the client to be at highest risk for self-harm?
- A. Immediately after a family visit
- B. On the anniversary of significant life events in the client's life
- C. During the first few days after admission
- D. Approximately 2 weeks after starting antidepressant medication
Correct Answer: D
Rationale: The risk of self-harm increases about 2 weeks after starting antidepressants, as energy improves before mood stabilizes.
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A client who is depressed states, 'I think my family would be better off without me. They don't need to worry.' Which would be the most appropriate response by the nurse?
- A. Are you planning to commit suicide?
- B. What do you think they are worried about?
- C. You don't mean that. Your family loves you.
Correct Answer: A
Rationale: Directly asking about suicidal plans addresses potential ideation, ensuring safety and opening further assessment.
A client who has been discharged home on Celexa (citalopram) calls the nurse complaining that the medication causes her to feel too drowsy. The nurse should make which of the following suggestions?
- A. Make an appointment to change to a different medication.
- B. Take the medication at night.
- C. Be patient while this early side effect subsides.
- D. Skip a dose if drowsiness is excessive.
Correct Answer: B
Rationale: Taking citalopram at night minimizes daytime drowsiness, a common side effect, improving adherence.
The nurse is teaching a 70-year-old man about his depression. Which statement by the client would indicate that teaching has been effective?
- A. All old people get depressed at times.
- B. I'm glad I'll feel better in 2 or 3 days.
- C. I never knew depression could just happen for no specific reason.
- D. When I reduce the stress in my life, the depression will go away.
Correct Answer: C
Rationale: Recognizing that depression can be endogenous without an external cause indicates effective understanding of the illness.
A client with bipolar disorder is admitted to the psychiatric unit. The client is talking loudly, walking back and forth rapidly, and exhibiting a short attention span. Which nursing intervention should occur first?
- A. Decrease the client's environmental stimuli.
- B. Give the client feedback about his behavior.
- C. Introduce the client to other staff on the unit.
- D. Tell the client about hospital rules and policies.
Correct Answer: A
Rationale: Reducing environmental stimuli is the priority to help calm an agitated client with bipolar disorder.
A client who just went through an upsetting divorce is threatening to commit suicide with a handgun. The client is involuntarily admitted to the psychiatric unit. Which nursing diagnosis has the highest priority?
- A. Hopelessness related to recent divorce.
- B. Ineffective coping related to inadequate stress management.
- C. Spiritual distress related to conflicting thoughts about suicide and sin.
- D. Risk for suicide related to a highly lethal plan.
Correct Answer: D
Rationale: The risk for suicide with a lethal plan is the highest priority, as safety is paramount in this situation.