Substance Abuse and Abuse Q 68
The nurse is caring for a severely depressed client who has just been admitted to the in-client psychiatric unit. Which of the following is a priority of care?
A. Nutrition
B. Elimination
C. Rest
D. Safety
Correct Answer: D. Safety
Safety is a priority of care for the depressed client. Precautions to prevent suicide must be a part of the plan. Identify the level of suicide precautions needed. If there is a high-risk, does a hospitalization require it? Or if there is a low risk, will the client be safe to go home with supervision from a family member or a friend? A client with a high-risk will require constant supervision and a safe environment.
Option A: Encourage small, high-calorie, and high-protein snacks and fluids frequently throughout the day and evening if weight loss is noted. Minimize weight loss, constipation, and dehydration. Encourage eating with others. Increases socialization, decreases focus on the food. Weight the client weekly and observe the eating patterns of the client. Give the information needed for revising the intervention.
Option B: Monitor intake and output, especially bowel movements. Most of the depressed clients are constipated. If this problem is not addressed, it can lead to fecal impaction. Encourage the intake of nonalcoholic and non-caffeinated fluids, 6 to 8 glasses a day. Fluids can help prevent constipation. Offer fiber-rich foods and periods of exercise. Roughage and exercise stimulate peristalsis and help evacuation of fecal material.
Option C: Provide rest periods after activities. Fatigue can intensify feelings of depression. Encourage relaxation measures in the evening (e.g., drinking warm milk, back rub, or tepid bath). These measures induce sleep and relaxation. Encourage the client to get up and dress and to stay out of bed during the day. Minimizing sleep during the day increases the likelihood of sleep at night. Reduce environmental and physical stimulants in the evening; Provide decaffeinated coffee, soft music, soft lights, and quiet activities.