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Difficulty: MediumMental Health Concepts

An adolescent client hospitalized for major depressive disorder has displayed severe anhedonia and psychomotor retardation for the past two weeks. Today, the client emerges from their room smiling, exhibiting unusually high energy, and gives a cherished guitar pick to another client. Which action is the priority for the nurse?

  1. Implement direct, continuous one-to-one observation of the client.Answer
  2. B
    Document the positive response to the current psychiatric treatment plan.
  3. C
    Ask the client why they decided to give away their cherished item today.
  4. D
    Delegate the task of interviewing the client about their mood change to the unlicensed assistive personnel.

Answer

The nurse must implement direct, continuous one-to-one observation to ensure the client's immediate safety.
The correct action directly protects the client from self-harm. When a severely depressed client suddenly appears happy, energetic, and begins giving away personal belongings, it is a major red flag. It often indicates that the client has formulated a specific suicide plan and feels a sense of relief. Because the client now has the energy to carry out the act, the nurse must immediately institute continuous one-to-one observation to prevent a suicide attempt.

Step-by-Step Solution

1
Analyze the change in the client's clinical presentation.
The client shows a sudden, drastic improvement in mood and energy, alongside giving away a prized possession.
Recognizing abrupt shifts in behavior is essential in psychiatric nursing, as these changes often indicate a shift in risk level.
2
Correlate the behavioral change with potential risks.
The sudden lift in depression and giving away belongings strongly suggests the client has made a concrete suicide plan and now has the energy to execute it.
Clients with severe depression often lack the energy to commit suicide; an energy surge provides the means to act on suicidal ideation.
3
Determine the highest priority nursing intervention.
The immediate priority is maintaining a safe environment by initiating one-to-one observation.
According to Maslow's Hierarchy of Needs and basic safety principles, preserving the client's life supersedes all other assessments or documentation.

Key Concept

Suicide Risk Assessment and Safety Interventions
Estimated Time:1m 0s
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Topics

Mental Health Concepts

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