Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
A client with a 7-year history of major depressive disorder, stopped medication, flat, withdrawn, cries, sleeps, slowed movementsThe charge nurse should first assess the client who has a 7-year history of major depressive disorder, whose friend reports the client has stopped taking their medication, and who is flat, withdrawn, cries all the time, sleeps all the time, and has extremely slowed movements, due to the risk of
Correct answer
A
Rationale
The correct answer is A: suicide. The client's history of major depressive disorder, discontinuation of medication, and current symptoms of extreme sadness, social withdrawal, and psychomotor retardation raise concerns for suicide risk. The charge nurse should prioritize assessing for suicidal ideation or plans, as these symptoms can indicate an increased risk of self-harm or suicide. Dehydration (B), infection (C), and seizure (D) are not the immediate concerns based on the client's presentation. It is crucial to address the client's mental health and safety first before exploring other potential issues.