Author Question: A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be ... (Read 39 times)

lbcchick · **on:** Jul 19, 2018

A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?

1. Obtaining an order for locked seclusion until client is no longer suicidal.
2. Conducting 15-minute checks to ensure safety.
3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
4. Encouraging client to express feelings related to suicide.

Question 2

A client is diagnosed with major depressive episode. Which nursing diagnosis should a nurse assign to this client, to address a behavioral symptom of this disorder?

1. Altered communication R/T feelings of worthlessness AEB anhedonia
2. Social isolation R/T poor self-esteem AEB secluding self in room
3. Altered thought processes R/T hopelessness AEB persecutory delusions
4. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia

aham8f · **Reply #1 on:** Jul 19, 2018

Answer to Question 1

3
Rationale: The nurse's priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.

Answer to Question 2

2
Rationale: A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room addresses a behavioral symptom of major depressive episode. Other behavioral symptoms include psychomotor retardation, virtually nonexistent communication, curled-up position, and no attention to personal hygiene and grooming.