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A nurse is assessing a patient diagnosed with major depressive disorder. The patient expresses feelings of hopelessness and states, 'I don't think anything will ever improve.' What is the priority nursing intervention?
- A. Encourage the patient to engage in activities that improve mood.
- B. Assess the patient for suicidal thoughts and ideation.
- C. Provide the patient with positive affirmations and reassurances.
- D. Suggest that the patient take medications to help with their depression.
Correct Answer: B
Rationale: The priority intervention is to assess the patient's risk for suicide, as feelings of hopelessness can indicate a high risk for self-harm. Immediate action is necessary to ensure safety.
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A nurse asks a patient, 'If you had fever and vomiting for 3 days, what would you do?' Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct Answer: B
Rationale: Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of 'Call my doctor' if the patient's cognition and judgment are intact. If the patient responds, 'I would stop eating' or 'I would just wait and see what happened,' the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.
The nurse assesses an adult who is socially withdrawn and hoards. Which nursing diagnoses most likely apply to this individual? (Select all that apply.)
- A. Ineffective home maintenance
- B. Situational low self-esteem
- C. Chronic low self-esteem
- D. Disturbed body image
Correct Answer: A
Rationale: Shame regarding the appearance of one's home is associated with hoarding. The behavior is usually associated with chronic low self-esteem. Hoarding results in problems of home maintenance, which may precipitate injury. The self-concept may be affected, but not body image.
A patient states, 'I’m not worth anything I have negative thoughts about myself I feel anxious and shaky all the time Sometimes I feel so sad that I want to go to sleep and never wake up' Which nursing intervention should have the highest priority?
- A. Self-esteem–building activities
- B. Anxiety self-control measures
- C. Sleep enhancement activities
- D. Suicide precautions
Correct Answer: D
Rationale: Suicidal thoughts (D) demand immediate safety measures, outranking A, B, and C
A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?
- A. Implement suicide precautions.
- B. Offer high-calorie snacks and fluids frequently.
- C. Assist the patient to identify three personal strengths.
- D. Observe patient for therapeutic effects of antidepressant medication.
Correct Answer: A
Rationale: Implementing suicide precautions is the only option related to patient safety. The other options, related to nutrition, self-esteem, and medication therapy, are important but are not priorities.
A nurse is assessing a patient diagnosed with major depressive disorder. The patient states, 'I don't see the point in anything anymore. I don't care about my life.' What is the priority nursing action?
- A. Ask the patient about their suicidal thoughts and plans.
- B. Provide the patient with reassurance that their feelings will improve.
- C. Encourage the patient to engage in activities to improve mood.
- D. Encourage the patient to express their feelings and explore their hopelessness.
Correct Answer: A
Rationale: The priority action is to assess the patient's safety and risk for suicide. Asking directly about suicidal thoughts or plans allows for immediate intervention to prevent harm.