Nokea
A nurse on a mental health unit is caring for clients who have various depressive disorders. The nurse should identify which of the following client diagnoses as presenting the greatest risk for suicide?
- A. Premenstrual dysphoric disorder
- B. Seasonal affective disorder
- C. Major depressive disorder
- D. Persistent depressive disorder
Correct Answer: C
Rationale: The correct answer is C: Major depressive disorder. Clients with major depressive disorder are at the highest risk for suicide due to the severity of their symptoms, including feelings of hopelessness, worthlessness, and suicidal ideation. This diagnosis is associated with a higher rate of completed suicides compared to other depressive disorders. Clients with premenstrual dysphoric disorder (A) experience mood changes related to their menstrual cycle but do not typically have an increased risk of suicide. Seasonal affective disorder (B) is characterized by seasonal changes in mood and energy levels but is not typically associated with a high risk of suicide. Persistent depressive disorder (D) involves chronic depressive symptoms but does not necessarily indicate an increased risk of suicide.
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A nurse is caring for an adolescent who is experiencing indications of depression. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Irritability
- B. Euphoria
- C. Chronic pain
- D. Social withdrawal
- E. Changes in appetite
Correct Answer: A, C, D, E
Rationale: Depression in adolescents often presents with irritability, physical complaints (chronic pain), social withdrawal, and appetite changes.
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?
- A. Determining if the client has psychotic thinking
- B. Asking the client to identify the cause of the crisis
- C. Identifying the client's coping skills
- D. Identifying the client's support systems
Correct Answer: A
Rationale: The correct answer is A: Determining if the client has psychotic thinking. This is the highest priority because it directly addresses the client's immediate safety and well-being. Psychotic thinking can pose a significant risk to the client and others, requiring prompt intervention. Asking the client to identify the cause of the crisis (B), identifying coping skills (C), and support systems (D) are important but secondary to ensuring the client's safety. It is crucial to address any potential psychotic thinking first before delving into other aspects of the assessment.
A nurse is caring for a client who is extremely suspicious of the nursing staff and other clients. Which of the following nursing approaches is appropriate when establishing a therapeutic relationship with this client?
- A. Disclose some personal information to the client to demonstrate approachability.
- B. Wait for the client to initiate interaction.
- C. Approach the client frequently throughout the day for brief interactions.
- D. Adopt a neutral attitude when providing care.
Correct Answer: D
Rationale: The correct answer is D: Adopt a neutral attitude when providing care. This approach is appropriate because it helps to build trust with a suspicious client by not evoking any feelings of threat or manipulation. By maintaining a neutral attitude, the nurse can establish a safe and non-threatening environment for the client to gradually open up and develop a therapeutic relationship.
Other choices are incorrect because:
A: Disclosing personal information may blur professional boundaries and make the client more suspicious.
B: Waiting for the client to initiate interaction may prolong the time it takes to establish a connection.
C: Approaching the client frequently may overwhelm the client and reinforce their suspicions.
E, F, G: These options are not provided in the question, so they cannot be evaluated.
Which intervention should a nurse prioritize when caring for a client with alcohol use disorder?
- A. Helping the client identify positive personality traits
- B. Providing adequate hydration and rest
- C. Confronting denial and defense mechanisms
- D. Educating the client about alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing adequate hydration and rest. This intervention is crucial because individuals with alcohol use disorder often experience dehydration and fatigue due to excessive alcohol consumption. Hydration helps to flush out toxins and restore electrolyte balance, while rest supports physical and mental recovery. Helping the client identify positive personality traits (A) may be beneficial in building self-esteem but is not as urgent as addressing physical needs. Confronting denial and defense mechanisms (C) may lead to resistance and hinder the therapeutic relationship. Educating the client about alcohol misuse (D) is important but should be done after addressing immediate physical needs.
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
- A. "Perhaps you could call your children to see how they are doing."
- B. "Don't worry. I'll take good care of your parent while you are gone."
- C. "You are feeling drawn in two separate directions."
- D. "There's nothing you can do here. You should go home to your children."
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.