A behavioral health unit nurse is caring for a newly admitted client.
Complete the following sentence by using the lists of options:
The client demonstrates risk for
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
The client demonstrates risk for feelings of hopelessness due to powerlessness.
Choice A: Inadequate Nutrition
Reason: While the client ate only one bite of toast, which might suggest inadequate nutrition, the primary concern based on the provided information is not related to nutrition. The client’s symptoms and history point more towards emotional and psychological issues rather than nutritional deficiencies.
Choice B: An Unkempt Appearance
Reason: The client is described as wearing wrinkled sweatpants and a stained t-shirt, which indicates an unkempt appearance. However, this is more a symptom of their overall mental state rather than the primary risk factor. The unkempt appearance is a result of their depressive symptoms and feelings of hopelessness.
Choice C: Inappropriate Thought Process
Reason: There is no direct evidence in the provided information that the client is experiencing inappropriate thought processes. The client’s thoughts and feelings, such as sadness and hopelessness, are consistent with depression but do not indicate a disturbed or inappropriate thought process.
Choice D: Feelings of Hopelessness
Reason: The client explicitly states feeling “sad and hopeless.” This is a significant indicator of depression and is a primary concern. Feelings of hopelessness are a major risk factor for worsening depression and potential self-harm.
Choice E: Powerlessness
Reason: The client’s history of losing their parents and subsequent deep depression, along with their current lack of interest in activities and social connections, suggests a sense of powerlessness. This feeling of powerlessness can exacerbate their feelings of hopelessness and depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason:
Clients with PTSD often hold persistent negative beliefs about themselves, which is a core symptom of the condition. These beliefs may include thoughts of being bad, unworthy, or responsible for the traumatic event. This negative self-perception can contribute to feelings of shame, guilt, and low self-esteem, which are common among individuals with PTSD.
Choice B reason:
Talking excessively is not typically associated with PTSD. While some individuals may talk more when they are anxious or trying to avoid certain thoughts, it is not a diagnostic criterion or a common finding in PTSD. Instead, individuals with PTSD may avoid talking about the traumatic event and may be withdrawn or socially isolated.
Choice C reason:
Blaming others for one's own mistakes is not a characteristic finding in PTSD. Individuals with PTSD may experience heightened irritability or anger, but this symptom does not specifically include blaming others for personal mistakes. It is more common for individuals with PTSD to have distorted perceptions of blame related to the traumatic event, often blaming themselves when it is not warranted.
Choice D reason:
Difficulty falling or staying asleep is a common symptom of PTSD. Sleep disturbances, including insomnia, nightmares, and restless sleep, are frequently reported by individuals with PTSD. These issues can be directly related to hyperarousal and intrusive thoughts or memories of the traumatic event.
Choice E reason:
Having difficulty concentrating on tasks is another symptom commonly seen in individuals with PTSD. This difficulty can be due to intrusive thoughts, hyperarousal, or general distress related to the traumatic event. It can affect various aspects of daily life, including work, school, and social interactions.
Correct Answer is A
Explanation
Choice A reason:
Informing the client that they have the legal right to refuse treatment at any time is the correct action. Patients have the right to make decisions about their own healthcare, including the right to refuse treatment. This respects their autonomy and ensures that they are making informed decisions about their care.
Choice B reason:
Encouraging the client to have the procedure without addressing their concerns can be seen as coercive. It is important to understand the client's reasons for refusing the procedure and to provide information and support to help them make an informed decision.
Choice C reason:
Obtaining consent from the client's family member is not appropriate unless the client is unable to make decisions for themselves. If the client is competent, their decision should be respected, and family members should not be asked to override their wishes.
Choice D reason:
Requesting another nurse to review the procedure with the client might be helpful in providing additional information, but it should not be done with the intention of pressuring the client into agreeing to the procedure. The client's right to refuse should still be respected.
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