Nokea
Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Restrict visitors to family members only.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Reinforce statements regarding a will to live and realistic plans for the future.
Correct Answer: B,D,E
Rationale: Discussing suicide plans, encouraging expression of suicidal thoughts, and reinforcing hope are critical for safety and therapeutic support. Restricting visitors or limiting video games are less relevant.
You may also like to solve these questions
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.
The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?
- A. Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.
- B. Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.
- C. Alert the assigned staff to closely monitor the client and intervene as needed to reduce the risk of self-mutilation.
- D. Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.
Correct Answer: C
Rationale: Close monitoring and intervention are critical to prevent self-harm in a client showing signs of distress, prioritizing safety.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.
Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?
- A. Any history of heart disease.
- B. Familial history of mental illness.
- C. Current weight.
- D. Medication history.
Correct Answer: D
Rationale: Medication history is critical to identify potential drug interactions, especially with serotonergic drugs, to prevent serotonin syndrome. Heart disease history, familial mental illness, and weight are relevant but secondary. [Note: Document incorrectly lists A as correct; D is more appropriate per standard practice.]
Nurse Notes
0900
Pain assessment completed. The client's pain is 2/10. The client requests sleeping medication for the night. She states that she has horrible thoughts and memories about the house collapsing all the time and that it is keeping her from falling asleep. She states, "I used to be so happy before all of this happened. Now I can't seem to get out of this funk I am in." The client would also prefer to be in a quieter area of the unit as she is currently by the nurses' station and hears talking and alarms constantly.
1100
The nurse reviews the physician's orders for clonazepam and gives the medication as ordered.
1115
Start clonazepam 0.25 mg PO every 12 hours
What nursing interventions are appropriate for the client starting clonazepam? Select all that apply.
- A. Assist the client to the bathroom
- B. Assess mental status regularly
- C. Provide oral care at least twice a day
- D. Screen for orthostatic hypotension
- E. Monitor calcium levels
- F. Have an opioid agonist at the bedside
Correct Answer: B,C,D
Rationale: Assessing mental status, providing oral care, and screening for orthostatic hypotension are appropriate for clonazepam's CNS effects and side effects like dry mouth. Bathroom assistance, calcium monitoring, and opioid agonists are irrelevant.