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A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?
- A. Loss of interest in diversional activities.
- B. Social isolation.
- C. Refusal to address nutritional needs.
- D. Low self-esteem.
Correct Answer: C
Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.
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A client with obsessive-compulsive disorder (OCD) is undergoing behavioral therapy. Which outcome should the nurse recognize as an indication that the client is responding positively to therapy?
- A. The client reports increased frequency of obsessive thoughts.
- B. The client demonstrates a decrease in compulsive behaviors.
- C. The client expresses a desire to leave therapy early.
- D. The client avoids participating in exposure tasks.
Correct Answer: B
Rationale: A decrease in compulsive behaviors is a positive response to behavioral therapy for OCD. Behavioral therapy aims to reduce these behaviors and promote healthier coping mechanisms. Option A, reporting an increased frequency of obsessive thoughts, would indicate a lack of improvement or worsening of symptoms. Option C, expressing a desire to leave therapy early, suggests resistance or dissatisfaction with therapy. Option D, avoiding participation in exposure tasks, goes against the principles of exposure therapy, which is commonly used in OCD treatment to help clients confront their fears and reduce anxiety.
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.
The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?
- A. Opportunities to contribute to one's treatment plan.
- B. One-on-one dialogue sessions with the therapist.
- C. Regularly scheduled unit activities for peer interaction.
- D. Home visits to reintegrate into the family.
Correct Answer: C
Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.
A female client with a history of major depressive disorder is experiencing a worsening of symptoms. Which statement by the client indicates a potential risk for suicide?
- A. "I've been feeling more tired than usual."
- B. "I've been thinking about how much better everyone would be without me."
- C. "I've been having trouble sleeping lately."
- D. "I feel like I can't handle everything."
Correct Answer: B
Rationale: The client's statement about thinking that everyone would be better off without her indicates suicidal ideation. This statement is a significant warning sign for suicide risk and requires immediate intervention. Choices A, C, and D reflect common symptoms of depression but do not directly indicate suicidal thoughts or intentions. Feeling tired, having trouble sleeping, and feeling overwhelmed are typical symptoms of major depressive disorder but do not necessarily suggest an imminent risk of suicide like the statement in option B does.
A client is being treated with a tricyclic antidepressant (TCA). Which side effect should the nurse monitor for?
- A. Constipation and urinary retention.
- B. Increased appetite and weight loss.
- C. Sedation and blurred vision.
- D. Insomnia and dry mouth.
Correct Answer: A
Rationale: The correct answer is A: Constipation and urinary retention. Tricyclic antidepressants (TCAs) are known to have anticholinergic side effects, which include constipation and urinary retention. These side effects occur due to the inhibition of cholinergic receptors, leading to decreased gastrointestinal motility and relaxation of the detrusor muscle in the bladder. Choices B, C, and D are incorrect because increased appetite, weight loss, sedation, blurred vision, insomnia, and dry mouth are not typically associated with the use of TCAs. Monitoring for constipation and urinary retention is essential to prevent complications and ensure the client's safety.