Question

A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

Answer 1

Correct Answers:

Monitor for risk of self-harm.

Rationale :

🔴 Monitoring for risk of self-harm is the priority because safety always comes first in a client with major depressive disorder.

🔴 Clients with severe depression can experience hopelessness, worthlessness, and suicidal thinking, even if they do not openly express it.

🔴 The nurse must first assess for suicidal ideation, plan, intent, and access to means before focusing on other needs.

🔴 Early identification of self-harm risk allows the team to implement suicide precautions and protect the client from injury or death.

🔴 Although other interventions are important, they are secondary to immediate safety assessment.

Administer prescribed antidepressants.

🔴 Antidepressants are an important part of treatment, but they do not address the client's most immediate safety risk.

🔴 Medication effects also take time, so the nurse must first determine whether the client is at risk for self-injury or suicide.

Encourage adequate fluid intake.

🔴 Maintaining hydration is supportive care, but it is not the first priority in acute depression.

🔴 The nurse should address life-threatening risks before focusing on fluid intake.

Assist with activities of daily living.

🔴 Helping with ADLs is often necessary for a depressed client, especially when energy and motivation are low.

🔴 However, assistance with self-care is not more urgent than assessing for self-harm risk.

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Answer 2

Correct Answers:

"I see that you have on clean clothes and have combed your hair."

Rationale :

🔵 This statement is therapeutic because it is a simple observation of fact without judgment or interpretation.

🔵 Clients with major depressive disorder benefit from communication that is neutral, genuine, and nonthreatening.

🔵 Stating what the nurse sees helps acknowledge progress while allowing the client to respond in her own way.

🔵 This approach avoids pressuring the client or making assumptions about the client's mood or motivation.

🔵 Therapeutic communication should encourage expression while preserving the client's dignity and autonomy.

"Your mood must be lifting because you have on clean clothes and have combed your hair."

🔵 This response makes an assumption about the client's emotional state that may not be accurate.

🔵 The nurse should avoid interpreting behavior for the client and instead focus on objective observations.

"Why did you wear clean clothes and comb your hair today?"

🔵 Asking why can sound demanding or judgmental and may make the client feel defensive.

🔵 Therapeutic communication is more effective when the nurse uses observations rather than interrogative questioning.

"Oh, I'm so pleased that you finally put on clean clothes."

🔵 This response is approval-giving and can sound patronizing.

🔵 It shifts the focus to the nurse's feelings instead of supporting the client's own experience.

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Answer 3

Correct Answers:

Walking with the nurse in the courtyard

Rationale :

🟢 A client in the manic phase needs activities that are structured, noncompetitive, and low stimulating.

🟢 Walking with the nurse provides physical movement while limiting excess stimulation and social conflict.

🟢 One-to-one activities are preferred because they reduce the chance of escalation, distraction, or overstimulation from groups.

🟢 Clients in mania often have increased energy, poor judgment, and short attention span, so calm supervised activity is best.

🟢 This intervention helps channel energy safely while supporting behavioral control and therapeutic interaction.

Watching a video with a group in the day room.

🟢 Group settings can provide too much sensory stimulation for a client who is manic.

🟢 Noise, people, and activity may worsen distractibility or agitation.

Participating in a basketball game in the gym.

🟢 Competitive sports can increase excitement, impulsivity, and aggressive behavior in mania.

🟢 The client needs calm, supervised activity rather than high-energy group competition.

Joining a group discussion about a local election.

🟢 A group discussion is likely too stimulating and may trigger argumentative or intrusive behavior.

🟢 Clients in mania do better with brief, simple, one-on-one interventions.

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Answer 4

Correct Answers:

2 tablets

Rationale :

🟣 The ordered dose is 40 mg, and each tablet contains 20 mg.

🟣 To determine the number of tablets, divide the prescribed dose by the available dose: 40 mg ÷ 20 mg = 2 tablets.

🟣 This calculation confirms that the nurse should administer 2 tablets each day.

🟣 Accurate dosage calculation is essential to ensure the client receives the intended therapeutic effect without underdosing or overdosing.

🟣 The nurse should always verify the order, the tablet strength, and the final calculation before administration.

3 tablets

🟣 3 tablets would equal 60 mg, which is more than the prescribed dose.

🟣 Administering this amount could expose the client to an unnecessary risk of adverse effects.

4 tablets

🟣 4 tablets would equal 80 mg, which is double the ordered daily dose.

🟣 This would be a medication error and is not supported by the prescription.

1 tablet

🟣 1 tablet provides only 20 mg, which is half the prescribed dose.

🟣 Giving this amount would result in underdosing and may reduce treatment effectiveness.

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Answer 5

Correct Answers:

"I don't have anyone I can talk to about my problems."

Rationale :

🟠 This statement requires further intervention because it reflects social isolation and lack of a support system, which are important suicide risk factors.

🟠 Adolescents with depression are at greater risk when they feel alone, disconnected, or unable to reach out for help.

🟠 The absence of trusted support may increase hopelessness and reduce the likelihood that the client will seek assistance during a crisis.

🟠 The nurse should explore this statement further and assess for current suicidal thoughts, intent, and protective factors.

🟠 Identifying limited support is essential for planning safety measures and strengthening the client's coping resources.

"I have not used drugs in 6 weeks."

🟠 This statement suggests a positive behavior change and may indicate improved self-control.

🟠 Although substance use history remains important, this statement alone is not the most urgent concern.

"I think that I missed two math tutoring classes last week, but I can still catch up."

🟠 This response reflects some awareness of responsibility and future planning.

🟠 It does not indicate the same level of isolation or risk as having no one to talk to.

"I have been participating in my local YMCA after-school dance program again."

🟠 Re-engaging in enjoyable activities is generally a positive sign of improved functioning.

🟠 Participation in structured social activity can serve as a protective factor against worsening depression.

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Answer 6

Correct Answers:

Current mental state and risk of self-harm or harm to others

Rationale :

🟡 A voluntarily admitted client generally has the right to request discharge, but the nurse must first consider the client's current mental state and risk of harm.

🟡 If the client poses a danger to self or others, the facility may need to begin procedures for involuntary hold or further evaluation according to law and policy.

🟡 Safety assessment is essential because the client's legal rights must be balanced with the duty to protect the client and the public.

🟡 The nurse should assess for suicidal ideation, homicidal ideation, psychosis, impulsivity, and ability to care for self.

🟡 This consideration is the most important factor in determining the appropriate response to the discharge request.

The facility's occupancy and bed availability

🟡 Bed availability does not determine whether a client can safely be discharged.

🟡 The decision must be based on clinical safety and legal criteria, not census status.

The client's previous treatment history

🟡 Treatment history may provide useful background, but it is not the most immediate concern when a client wants to leave.

🟡 The nurse must focus first on the client's present risk level.

The client's ability to pay for continued care

🟡 A client's finances should not determine the immediate clinical response to a discharge request.

🟡 Safety, legal rights, and mental status are the priority considerations.

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Answer 7

Correct Answers:

Thyroid hormone assay

Rationale :

🔶 Lithium therapy is associated with adverse effects involving the thyroid gland, including hypothyroidism.

🔶 For that reason, the nurse should verify that a thyroid hormone assay has been completed as part of routine monitoring.

🔶 Long-term lithium use can alter endocrine function, so thyroid status must be checked regularly to detect complications early.

🔶 Monitoring supports safe administration and helps identify whether the medication is causing physiologic changes that need treatment.

🔶 Ongoing assessment for clients taking lithium should also include renal function and serum lithium levels, but among these choices, thyroid testing is the best answer.

Liver function tests

🔶 Liver function tests are not the primary routine monitoring focus for lithium therapy.

🔶 Lithium is more strongly associated with effects on the thyroid and kidneys.

Erythrocyte sedimentation rate

🔶 The erythrocyte sedimentation rate is a nonspecific marker of inflammation.

🔶 It is not a standard monitoring test related to lithium administration.

Brain natriuretic peptide

🔶 Brain natriuretic peptide is primarily used in the evaluation of heart failure.

🔶 It does not monitor the common adverse effects of lithium therapy.

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Answer 8

Correct Answers:

"I'll just sit here with you for a few minutes then."

Rationale :

⚫ This is a therapeutic response because it offers presence and support without forcing the client to speak.

⚫ Clients with depression may not be ready to talk, but they can still benefit from knowing the nurse is available and emotionally present.

⚫ Sitting quietly with the client communicates acceptance, respect, and compassion.

⚫ This approach avoids placing pressure on the client while still reducing feelings of isolation.

⚫ Therapeutic use of self is often one of the most effective nursing interventions for a client experiencing sadness and withdrawal.

"It might help you feel better if you talk about it."

⚫ This response gently pushes the client to talk when the client has already said they do not want to.

⚫ The nurse should support the client's current needs instead of directing the interaction.

"I understand. I've felt like that before, too."

⚫ This shifts the focus from the client to the nurse's own experience.

⚫ Therapeutic communication should remain centered on the client's feelings and needs.

"Why are you feeling so down?"

⚫ Asking why can make the client feel pressured or judged.

⚫ Clients with depression may not be able to explain their feelings clearly, and the question may hinder communication.

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Answer 9

Correct Answers:

Right to due process of law

Rationale :

💎 The right to due process of law supports the facility's response because clients in mental health settings are protected by legal procedures when liberty is restricted.

💎 If a client demands discharge, the facility cannot arbitrarily detain the client without following the appropriate legal process.

💎 Due process ensures that decisions about continued hospitalization are based on evidence of danger to self, danger to others, or inability to care for self, rather than on opinion alone.

💎 This right protects both the client and the facility by requiring lawful review and proper documentation.

💎 In mental health care, due process is central whenever there is a question about restricting a client's freedom.

Equal coverage of treatment expenses

💎 Insurance or payment coverage does not determine the legal basis for holding or releasing a client.

💎 The issue in this situation is the client's civil liberty and legal procedure, not treatment cost.

Confidentiality of medical records

💎 Confidentiality protects the privacy of health information.

💎 It does not govern the legal process related to discharge from a mental health facility.

Patient's right to refuse treatment

💎 Clients do have rights regarding treatment decisions, but discharge from a mental health facility may involve separate legal criteria.

💎 When safety concerns exist, the facility must follow due process rather than relying only on treatment refusal rights.

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Answer 10

Correct Answers:

Right to due process of law

Rationale :

⭐ The right to due process of law means the client is entitled to a fair legal process if the facility believes discharge should be delayed or denied.

⭐ Mental health facilities must follow established procedures before restricting a client's freedom, especially when considering involuntary detention.

⭐ This right ensures that decisions are based on current risk and legal standards, not personal preference or convenience.

⭐ Due process protects the client's civil rights while also allowing the facility to intervene when there is a credible safety threat.

⭐ The nurse should understand that discharge-related decisions in psychiatric settings must be handled within the framework of law and patient rights.

Equal coverage of treatment expenses

⭐ Payment or insurance issues are not the legal basis for determining whether a client can leave a mental health facility.

⭐ The situation concerns liberty and legal procedure, not financial coverage.

Confidentiality of medical records

⭐ Confidentiality refers to protecting the client's private health information.

⭐ It does not explain the facility's legal authority to respond to a discharge demand.

Patient's right to refuse treatment

⭐ Refusing treatment is a patient right, but it is not the core legal principle governing discharge disputes in psychiatric care.

⭐ When a facility responds to a request to leave, the supporting legal framework is due process of law.

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QLexNursing

1 :
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

3 :
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

4 :
A nurse is preparing to administer fluoxetine to a patient admitted for a mental health crisis and must calculate the correct dosage. The order is for 40 mg daily, and the medication is available in 20 mg tablets. How many tablets should the nurse administer each day?

5 :
A nurse is caring for an adolescent client who has a history of depression and suicidal ideation. Which of the following client statements should the nurse identify as requiring further intervention?

6 :
If a client voluntarily admitted to a mental health facility expresses a wish to leave, what should the nurse consider?

7 :
A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

8 :
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

9 :
A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?

10 :
A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?

QLexNursing

1 : A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

3 : A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

4 : A nurse is preparing to administer fluoxetine to a patient admitted for a mental health crisis and must calculate the correct dosage. The order is for 40 mg daily, and the medication is available in 20 mg tablets. How many tablets should the nurse administer each day?

5 : A nurse is caring for an adolescent client who has a history of depression and suicidal ideation. Which of the following client statements should the nurse identify as requiring further intervention?

6 : If a client voluntarily admitted to a mental health facility expresses a wish to leave, what should the nurse consider?

7 : A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

8 : A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

9 : A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?

10 : A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?

1 :
A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse's priority?

3 :
A nurse is caring for a client who has bipolar disorder and is in the manic phase. The client says he is bored. Which of the following activities is appropriate for the nurse to suggest to this client?

4 :
A nurse is preparing to administer fluoxetine to a patient admitted for a mental health crisis and must calculate the correct dosage. The order is for 40 mg daily, and the medication is available in 20 mg tablets. How many tablets should the nurse administer each day?

5 :
A nurse is caring for an adolescent client who has a history of depression and suicidal ideation. Which of the following client statements should the nurse identify as requiring further intervention?

6 :
If a client voluntarily admitted to a mental health facility expresses a wish to leave, what should the nurse consider?

7 :
A nurse is caring for a client who has bipolar disorder and has been taking lithium for 1 year. Before administering the medication, the nurse should check to see that which of the following tests have been completed?

8 :
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?

9 :
A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?

10 :
A client in a mental health facility demands discharge against medical advice. Which legal right supports the facility's response to such a request?