a nurse is assessing a client who has been diagnosed with major depressive disorder the client states i feel like i cant go on which of the following
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Nursing Elites

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ATI Mental Health Practice B

1. When assessing a client diagnosed with major depressive disorder who states, 'I feel like I can't go on,' which of the following actions should the nurse take first?

Correct answer: B

Rationale: The priority action for the nurse is to assess the client's risk for suicide. By asking if the client has a plan to commit suicide, the nurse can determine the immediate safety of the client and take appropriate interventions to prevent harm. Administering antidepressant medication is not the first action to take in this situation as assessing the client's safety is the priority. Encouraging the client to attend a support group or contacting the client's family, although beneficial, are not immediate actions to ensure the client's safety in a crisis situation.

2. During an assessment of a client with suspected substance use disorder, which of the following findings should the nurse expect? Select one that doesn't apply.

Correct answer: A

Rationale: In clients with substance use disorder, common findings include increased tolerance to the substance, withdrawal symptoms when not using it, and unsuccessful attempts to cut down or control use. Feelings of hopelessness are not typically a direct manifestation of substance use disorder. Instead, feelings of hopelessness may be associated with other mental health conditions or situational factors. Therefore, the correct answer is A. Choices B, C, and D are all expected findings in clients with substance use disorder.

3. Which statement demonstrates a well-structured attempt at limit setting?

Correct answer: A

Rationale: Choice A, 'Hitting me when you are angry is unacceptable,' demonstrates a well-structured attempt at limit setting because it clearly defines the unacceptable behavior without ambiguity. This statement sets a clear boundary and clearly communicates the consequence for the behavior. In contrast, choices B, C, and D are less effective in setting limits as they are either vague expectations or commands without specific consequences for crossing the limit.

4. When preparing a teaching plan for a client with generalized anxiety disorder, which information should a healthcare professional include?

Correct answer: C

Rationale: The correct answer is C: Practicing relaxation techniques. This is a crucial aspect of managing generalized anxiety disorder. Techniques like deep breathing, progressive muscle relaxation, and mindfulness can effectively reduce anxiety levels and promote calmness. These techniques provide valuable coping mechanisms to help individuals with generalized anxiety disorder deal with stress and anxiety.\nChoice A, avoiding caffeine and other stimulants, can be beneficial but is not as central to managing generalized anxiety disorder as practicing relaxation techniques.\nChoice B, engaging in regular physical activity, is also helpful for managing anxiety, but relaxation techniques are more specific and targeted for addressing symptoms of generalized anxiety disorder.\nChoice D, keeping a journal of anxiety triggers, may be a useful strategy to identify triggers but does not directly address the immediate management of anxiety symptoms, unlike practicing relaxation techniques.

5. A new psychiatric nurse states, 'This client's use of defense mechanisms should be eliminated.' Which is a correct evaluation of this nurse's statement?

Correct answer: A

Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms help individuals reduce anxiety during times of stress. It is crucial for the nurse to understand that defense mechanisms serve a purpose and can be a normal part of coping. However, if defense mechanisms significantly hinder the client's ability to develop healthy coping skills, they should be addressed and explored. Eliminating defense mechanisms entirely without considering the individual's overall coping strategies can be counterproductive and may lead to increased distress for the client. Choice B is incorrect because not all defense mechanisms are maladaptive; some can be adaptive and helpful. Choice C is incorrect because labeling individuals as having weak ego integrity based on their use of defense mechanisms is stigmatizing and oversimplified. Choice D is incorrect because fostering and encouraging defense mechanisms without differentiation can lead to maladaptive behaviors and reliance on these mechanisms instead of healthier coping strategies.

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