Question

A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following is the highest priority action by the nruse?

A. Placing the client on one-to-one observation.
B. Assisting the client to perform ADLs.
C. Encouraging the client to participate in counseling.
D. Teaching the client about medication adverse effects.

ATI RN Mental Health Nursing Modules Ch. 12 Notes

Answer 1

The highest priority action for a nurse admitting a client with major depressive disorder and comorbid anxiety disorder is to ensure safety through one-to-one observation if the client is at risk for harm (Option A). Other nursing actions include assisting with ADLs, encouraging counseling, and teaching about medication effects once safety is assured.

Step-by-step explanation:

When admitting a client with major depressive disorder and comorbid anxiety disorder, the highest priority action by the nurse is contextual and depends on the client's current presentation. If the client is at risk for harm to themselves or others, then placing the client on one-to-one observation is the highest priority to ensure safety (Option A).

However, if safety is not an immediate concern, then the nurse may prioritize other interventions such as assisting with Activities of Daily Living (ADLs), encouraging participation in counseling, or teaching about medication adverse effects.

These actions support the client's overall care and treatment plan in a holistic manner, addressing both psychological and physical health needs.