Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?
A. Significant weight loss
Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.
B. Markedly neglected hygiene
While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.
C. Psychomotor retardation
Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.
D. Poor problem-solving skills
Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.
This question is an excerpt from Nurse Dive's nursing test bank - RN Mental Health 2019 With NGN Proctored Exam. Take the full exam now
Full Explanation
Choice A reason:
Significant weight loss in a patient with major depressive disorder is a red flag for clinicians. It can signify a high risk of complications, including malnutrition, electrolyte imbalance, and weakened immunity. In the context of depression, it may also reflect a lack of self-care or even suicidal tendencies, which require immediate attention.
Choice B reason:
While markedly neglected hygiene is concerning and indicative of a patient's inability to perform daily self-care activities, it is not typically considered an immediate life-threatening issue. However, it does warrant intervention to prevent potential secondary infections or complications.
Choice C reason:
Psychomotor retardation is a symptom that can manifest in major depressive disorder, characterized by slowed physical movements and cognitive processing. Although it impacts the quality of life and daily functioning, it is not usually a direct indicator of an acute life-threatening condition.
Choice D reason:
Poor problem-solving skills are part of the cognitive symptoms of depression, affecting a patient's ability to manage daily tasks and make decisions. While this can significantly impact a patient's life, it is not as urgent as significant weight loss, which can have immediate physical health consequences.
Similar Questions
What is the priority finding to report to other disciplines for a client who has major depressive disorder?
A. Significant weight loss
Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.
B. Markedly neglected hygiene
C. Psychomotor retardation
D. Poor problem-solving skills
Full Explanation
Significant weight loss. This finding indicates a risk for malnutrition, dehydration, and electrolyte imbalance, which can affect the client's physical and mental health. The other findings are also important to report, but they are not as urgent as weight loss.
Who should the nurse contact to assist the client with housing placement for discharge?
A. Recreational therapist
B. Occupational therapist
C. Clinical nurse specialist
D. Social worker
This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.
Full Explanation
This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.
What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?
A. Sore throat
This finding could indicate agranulocytosis, a potentially life-threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.
B. Heart rate 104/min
C. Nausea
D. Random blood glucose 130 mg/dL
Full Explanation
This finding could indicate agranulocytosis, a potentially life threatening adverse effect of clozapine that causes a severe decrease in white blood cells and increases the risk of infection. The other findings are also important to monitor, but they are not as critical as sore throat.