A client has been severely depressed and suicidal. After admission to an inpatient psychiatric unit, antidepressant medication is administered. As the client becomes more energized and communicative, what should be the priority nursing intervention for this client?

Correct Answer: C

Rationale: Correct Answer: C - Increasing the vigilance regarding the client's suicidal precautions Rationale: 1. The client was admitted for severe depression and suicidal ideation, indicating a high suicide risk. 2. Antidepressants can initially increase energy before improving mood, potentially raising suicide risk. 3. As the client becomes more energized and communicative, the risk of impulsive actions, including suicide, may increase. 4. Therefore, increasing vigilance and maintaining strict suicidal precautions are crucial to ensure the client's safety. Summary of Incorrect Choices: A: Allowing unsupervised passes may expose the client to triggers or opportunities for self-harm. B: Group activities can be beneficial but do not address the immediate safety concern of suicidal risk. D: Assuming suicidal potential has decreased prematurely can be dangerous, as the client may still be at risk.

Correct Answer: B

Rationale: The correct answer is B: Absence of peripheral edema. Improvement in heart failure is indicated by reduced fluid retention, leading to decreased peripheral edema. This suggests better cardiac function and reduced congestion in the body. Pale and cool extremities (A) can indicate poor circulation. Urine output of 60 mL every 4 hours (C) may be inadequate for adequate fluid removal. Complaints of increasing dyspnea (D) suggest worsening heart failure.

Correct Answer: D

Rationale: The correct answer is D because both A and B scenarios present limitations to blinding with a placebo control group. In scenario A, using a placebo in dangerous treatments like surgery would be unethical due to potential harm. In scenario B, patient participation is crucial, making it difficult to blind the trial. Option C is incorrect as it specifically mentions a standard placebo potentially harming diabetics, which is not a general rule for all clinical trials.

Correct Answer: A

Rationale: The correct answer is A because it demonstrates therapeutic communication and empathy by acknowledging the patient's perspective and inviting further discussion. By exploring the patient's reasons for wanting to stop the medication, the nurse can address underlying concerns and provide education on the importance of medication adherence in managing schizophrenia. Choice B is incorrect as it undermines the patient's autonomy and fails to address the patient's reasons for stopping the medication. Choice C is partially correct in acknowledging the patient's perspective but lacks the active engagement needed to assess and address the patient's decision. Choice D is incorrect as it expresses fear without exploring the patient's beliefs and reasons, which can lead to resistance and non-compliance.

Correct Answer: B

Rationale: The correct answer is B because it provides the patient with a clear and concise explanation of how the medication works to address their depression by correcting a chemical imbalance. This response educates the patient on the purpose of SSRI medications, which helps them understand the potential benefits of treatment. Choice A is incorrect because it oversimplifies the mechanism of action of SSRIs and may not effectively address the patient's concerns. Choice C is incorrect as it focuses more on the general benefits of SSRIs rather than directly addressing the patient's lack of understanding. Choice D is incorrect as it does not provide the patient with the information needed to make an informed decision about medication.