C. 1. A patient diagnosed with major depressive disorder has lost 20 pounds in 1 month. The patient has chronic low self

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C 1 A Patient Diagnosed With Major Depressive Disorder Has Lost 20 Pounds In 1 Month The Patient Has Chronic Low Self 1 (85.27 KiB) Viewed 66 times

C. 1. A patient diagnosed with major depressive disorder has lost 20 pounds in 1 month. The patient has chronic low self-esteem and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this priority: "Patient will refrain from gestures and attempts to harm self"? a. Implement suicide prevention interventions. b. Frequently offer high-calorie snacks and fluids. C. Assist the patient to identify three personal strengths. d. Observe patient for therapeutic effects of antidepressant medication. 2. A nurse assesses an older adult patient brought to the emergency department by a family member. The patient was wandering outside, saying, "I can't find my way home." The patient is confused and unable to answer questions. What is the nurse's best action to provide effective nursing care? a. Document the patient's mental status. Obtain other assessment data from the family member. b. Record the patient's answers to questions on the nursing assessment form. Ask an advanced practice nurse to perform the assessment interview. d. Call for a mental health advocate to maintain the patient's rights. 3. A nurse documents: "Patient is mute, despite repeated efforts to elicit speech. Makes no eye contact. Is inattentive to staff. Gazes off to the side or looks upward rather than at the speaker." Which nursing diagnosis should be considered? Defensive coping b. Decisional conflict Risk for other-directed violence d. Impaired verbal communication 4. A nurse assesses a confused older adult. The nurse experiences sadness and reflects, "The patient is like one of my grandparents, so helpless." What feelings does the nurse describe? Transference b. Countertransference c. Catastrophic reaction d. Defensive coping reaction 5. A patient says, “I'm still on restriction, but I want to attend some off-unit activities. Would you ask the doctor to change my privileges? What is the nurse's best response? a. “Why are you asking me when you're able to speak for yourself?" b. "I will be glad to address it when I see your doctor later today." c. “That's a good topic for you to take up with your doctor." d. "Do you think you can't speak to a doctor?" a. c. a.