The nurse is working with a client who has been admitted to the ...

[cmoore54]

The nurse is working with a client who has been admitted to the hospital with a psychotic depression. Which of the following nursing diagnoses is the MOST important for this client at this time?
 
  a. Social Isolation
  b. Powerlessness
  c. Risk for Injury
  d. Self-Care Deficit

Question 2

The nurse interviewing a client on admission suspects this client may be depressed. The nurse knows that there are self-rating scales that the client can complete to assist in the detection of depression.
 
  Two of the MOST common self-rating scales the nurse might ask the client to complete are the: a. Stanford and the WISC
  b. Beck and the Zung
  c. Miller and the GRE
  d. Rorschach and the MMPI

[lindahyatt42]

Answer to Question 1

C
Because the client has been admitted for depression, the most important diagnosis would be Risk for Injury. Individuals who are depressed pose a possible safety risk to themselves. Some may experience feelings of hopelessness and see suicide as the only option. While issues of social isolation, powerlessness, and self-care deficit are a concern for the depressed client, safety is always the priority. The nurse must protect the client against self-harm.

Answer to Question 2

B
The two most common self-rating scales used with clients who may be depressed are the Beck Depression Inventory and the Zung Self-Rating Depression Scale. The Beck Depression Inventory is a 21-item scale used with individuals ages 13 and older. It measures the severity of depression. The Zung Self-Rating Depression Scale is a 20-item scale that measures four common characteristics of depression.

[cmoore54]

Thank you

[lindahyatt42]

Happy to help you