A nurse is caring for a patient diagnosed with major depressive disorder. The patient states, 'I don't see the point in anything anymore. I just want to give up.' What is the priority nursing intervention?

Correct Answer: A

Rationale: The correct answer is A because assessing the patient's suicidal thoughts and plan is the priority in this situation to ensure patient safety. By asking about suicidal ideation, the nurse can determine the level of risk and take appropriate actions to prevent self-harm. Choice B is incorrect as encouraging the patient to talk about their feelings is important but not the priority when immediate safety is at stake. Choice C is incorrect as simply reassuring the patient without assessing their suicidal ideation can be dangerous if the patient is at high risk of self-harm. Choice D is also incorrect as providing positive affirmations and support may not address the underlying risk of suicidal ideation.

Correct Answer: A

Rationale: The correct answer is A. Asking the patient directly about thoughts of self-harm or suicide is the priority intervention because it allows the nurse to assess the patient's risk and take appropriate actions to ensure safety. It is essential to address potential suicidal ideation promptly. Encouraging group therapy (B) may be beneficial but is not as urgent as assessing for suicidal thoughts. Offering reassurance and support (C) is important but does not directly address the risk of suicide. Monitoring for signs of agitation or psychotic symptoms (D) is also important but not as crucial as directly assessing for suicidal ideation.

Correct Answer: A

Rationale: The correct answer is A: Nonverbal communication. In this scenario, the patient's lack of eye contact, lowered chin, and looking at the floor all indicate nonverbal cues. Nonverbal communication plays a crucial role in conveying feelings and emotions. The patient's body language suggests feelings of sadness, low self-esteem, or discomfort, which are common in major depressive disorder. Nonverbal communication is an essential aspect of interpersonal communication and can provide valuable insights into a person's emotional state. Summary: B: A message filter - Incorrect. A message filter refers to factors that distort or block communication, such as noise or distractions. The patient's behavior does not represent filtering of messages. C: A cultural barrier - Incorrect. Cultural barriers involve differences in norms, values, or communication styles. The patient's nonverbal cues are more likely related to their emotional state rather than cultural factors. D: Social skills - Incorrect. Social skills involve the ability to interact effectively with others. The

Correct Answer: A

Rationale: The correct answer is A because it acknowledges the patient's feelings without judgment or disagreement, showing empathy and understanding. Option B dismisses the patient's emotions and offers unsolicited reassurance. Option C could come off as confrontational and may make the patient feel defensive. Option D assumes the patient's beliefs and may not address the underlying emotional distress.

Correct Answer: A

Rationale: The correct answer is A: Provide a quiet and low-stimulation environment. During the manic phase of bipolar disorder, patients often experience heightened agitation and sensory overload. Creating a calm and low-stimulation environment can help reduce the intensity of their symptoms and promote relaxation. This intervention is crucial to prevent exacerbation of manic behaviors and potential harm to the patient or others. Summary: - Choice B: Encouraging social activities may further stimulate the patient, worsening manic symptoms. - Choice C: While medication is important, creating a calming environment is the immediate priority. - Choice D: Firm limits may provoke resistance and escalate the situation, rather than de-escalate it.