A patient diagnosed with major depressive disorder has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken antidepressant medication for 1 week. Which nursing intervention has the highest priority?

Correct Answer: A

Rationale: In this scenario, the highest priority nursing intervention is option A) Implement suicide precautions. This is because the patient is displaying severe symptoms of major depressive disorder, including significant weight loss, chronic low self-esteem, and a plan for suicide. These indicators suggest that the patient is at immediate risk of self-harm or suicide, making safety the top priority. Implementing suicide precautions involves closely monitoring the patient, removing any potential means of self-harm, and providing constant supervision to ensure their safety. This intervention is crucial in preventing harm and protecting the patient's well-being. The other options are not the highest priority in this situation: - Option B) Offering high-calorie snacks and fluids is important for addressing weight loss, but it is not the most critical intervention when the patient is at risk of suicide. - Option C) Assisting the patient to identify personal strengths is a valuable therapeutic intervention, but it is not the most urgent when the patient's safety is in jeopardy. - Option D) Observing the patient for therapeutic effects of antidepressant medication is essential for long-term treatment; however, in this case, immediate safety concerns take precedence over monitoring medication effects. In an educational context, this question highlights the importance of prioritizing interventions based on the patient's immediate needs and level of risk. It underscores the critical role of nurses in assessing, intervening, and managing psychiatric emergencies to ensure patient safety and well-being.

Correct Answer: C

Rationale: The correct answer to this question is option C) A person returning to college after an employer ceased operations. This situation would most necessitate a complete assessment of a person's stress status and coping abilities because it involves a significant life change that not only impacts the individual's financial stability but also their sense of identity and future prospects. Returning to college after losing a job due to company closure can lead to feelings of uncertainty, financial strain, self-doubt, and the need to adapt to a new routine and environment. This transition can significantly increase stress levels and require the individual to develop new coping strategies to manage the challenges they are facing. Option A) about being assigned more responsibility at work may cause stress, but it does not necessarily indicate a major life change that would warrant a complete assessment of stress status and coping abilities. Option B) about a parent relocating for a job change also involves a significant life event, but it may not be as impactful on the individual's overall well-being and coping abilities as losing a job and returning to school. Option D) about a man separating from his wife due to marital problems is indeed a stressful life event, but it is more focused on interpersonal relationships rather than a broad assessment of stress and coping abilities related to major life changes like job loss and educational transitions. In an educational context, understanding how different life events can impact an individual's stress levels and coping mechanisms is crucial for healthcare professionals, especially in the field of behavioral nursing. By recognizing the significance of certain life events and their potential effects on an individual's mental health, nurses can provide targeted support and interventions to help patients navigate these challenging situations effectively.

Correct Answer: B

Rationale: Eustress is beneficial stress; it motivates people to develop skills they need to solve problems and meet personal goals. Positive life experiences produce eustress. Going on a tropical vacation is an exciting, relaxing experience and is an example of eustress. Losing the family pet, worrying about employment security, and having financial problems are examples of distress, a negative experience that drains energy and can lead to significant emotional problems.

Correct Answer: D

Rationale: In this scenario, the most appropriate question for the nurse to ask the patient with a tentative diagnosis of generalized anxiety disorder is option D: "Do you find it difficult to control your worrying?" This question is the most suitable as it directly addresses a key symptom of generalized anxiety disorder, which is excessive and uncontrollable worrying. Option A is incorrect because it pertains more to post-traumatic stress disorder rather than generalized anxiety disorder. Option B is more indicative of social anxiety disorder, which is a different condition from generalized anxiety disorder. Option C is characteristic of obsessive-compulsive disorder, not generalized anxiety disorder. Educationally, understanding the rationale behind selecting the correct question is crucial for nurses in assessing and differentiating various mental health conditions. By asking targeted questions related to specific symptoms, nurses can provide more accurate assessments, leading to appropriate interventions and support for patients with mental health issues. This approach enhances patient care and ensures proper management of conditions like generalized anxiety disorder.

Correct Answer: A

Rationale: Teaching about symptoms of anxiety, their relation to precipitating stressors, and, in this case, the positive effects of anxiety will serve to reassure the patient. Advising the patient to discuss the experience with a health care provider implies that the patient has a serious problem. Listening without comment will do no harm but deprives the patient of health teaching. Antioxidant vitamin supplements are not useful in this scenario.