Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment.
These clinical features of the client’s depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
A . Nutritional status
B . Impaired thinking
C . Possible harm to self
D . Rest and activity impairment
Answer: C
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns.
(B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy asmotivation and interest increase.
(C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide.
(D) Rest and activity impairment may take time and further assessment to determine client’s sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.