A client diagnosed with major depressive disorder and experiencing suicidal ideation is showing signs of anxiety. Alprazolam (Xanax) is prescribed. Which assessment should be prioritized

Appeared in: RUHS, Jaipur, M.Sc Nursing Entrance Exam-2023

Explanation

The highest priority for any client expressing suicidal ideation is always patient safety and the prevention of self-harm.
Alprazolam, a benzodiazepine, is a CNS depressant that can sometimes cause paradoxical reactions, such as worsening depression or disinhibition, which could increase the risk of a client acting on suicidal thoughts.
Continuously assessing the client's mood and the intensity of their suicidal ideations is the most critical nursing action to ensure their immediate safety.
There is a significant risk that a client with suicidal ideation may attempt to hoard medication for an overdose attempt, which necessitates close monitoring of their mood and behavior.

Option A: Monitoring for withdrawal is necessary during the tapering or discontinuation of long-term benzodiazepine use, not when therapy is first initiated.
Option B: Patient education is a standard and important nursing intervention, but it is not a higher priority than immediate safety assessment and suicide prevention.
Option C: Nausea is a potential side effect, but it is not life-threatening and is considered a low-priority comfort issue compared to the imminent risk of suicide.

Clinical Relevance

Nursing practice connection: Use the key finding related to Prioritization of nursing care for a client with major depressive disorder and suicidal ideation to guide bedside assessment, documentation, and the next nursing action.
In psychiatric nursing, the principle of 'safety first' governs all actions. A client's risk of harm to self or others always outweighs other concerns like comfort, education, or long-term side effects.
Nurses must be vigilant for paradoxical effects of medications. While a benzodiazepine is given to reduce anxiety, it can disinhibit a depressed patient, lowering their impulse control and tragically increasing suicide risk.
What if? If the client was diagnosed with a generalized anxiety disorder without a history of depression or suicidal ideation, the priority might shift to teaching about side effects and the risk of dependence (Option B), as the immediate suicide risk would be much lower.

How to Approach the Question

First, identify the core problem and keywords in the question stem: 'major depressive disorder,' 'suicidal ideation,' and 'prioritized'.
Recognize that the presence of suicidal ideation immediately flags a major patient safety issue. In any prioritization question, safety is the highest priority.
Analyze the medication being given: Alprazolam. Recall that as a CNS depressant, it can have complex and sometimes paradoxical effects on mood and impulse control, especially in a depressed individual.
Evaluate each option based on the principle of safety. Ask yourself: 'Which action most directly addresses the immediate, life-threatening risk of self-harm?'
Option D directly assesses mood and suicide risk. Options A, B, and C address less urgent issues (long-term withdrawal, education, and a minor side effect). Therefore, Option D is the clear priority.

Concept Tested & Keywords

Concept Tested: Prioritization of nursing care for a client with major depressive disorder and suicidal ideation.
Stem keywords: major depressive disorder, suicidal ideation, anxiety, Alprazolam (Xanax)
Lead-in keywords: prioritized
Clinical cues: The combination of major depression and active suicidal ideation signals a high-risk safety situation that must be the top priority.

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E6 Guide to Mental Health & PSYCHIATRIC NURSING R Sreevani— Part 2 (pp 290-564 of 579) p. 254-256

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 2119-2121

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