A client diagnosed with major depressive episode hears voices ...

[lbcchick]

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]

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.

[lbcchick]

Thanks for the timely response, appreciate it

[jordangronback]

Gracias!