A client is admitted with abdominal pain, loss of appetite, and a weight loss of 25 lb (11 kg) in the last four months. During the admission assessment, the client describes to the nurse of having no interest in playing cards with friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

"Risk for self-directed violence as evidenced by feelings of hopelessness."

"Chronic low self-esteem as evidenced by feelings of worthlessness."

"Anxiety as evidenced by abdominal discomfort secondary to depression."

"Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months."

Answer and Explanation

The Correct Answer is A

A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.

B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.

C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.

D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["C","D","E","F","H"]

Explanation

A. Perform aggressive weight bearing exercises: Aggressive weight-bearing exercises may place too much strain on the joints, especially for someone with RA. Low-impact activities, such as swimming or walking, are generally recommended to avoid exacerbating joint damage or pain.

B. Anticipate dry eyes and mouth; no intervention is needed: While dry eyes and mouth can occur in autoimmune diseases like RA, particularly if the client has secondary Sjögren's syndrome, they should not be ignored. The nurse should advise the client to seek treatment for these symptoms, as interventions can provide relief.

C. Take hot showers to help relieve stiffness: Warm showers or baths can help reduce the stiffness and pain associated with rheumatoid arthritis (RA) by relaxing muscles and improving circulation. This can be an effective method to manage the morning stiffness that the client experiences.

D. Observe skin for any lesions: Skin lesions can be a result of certain medications or the disease process itself. RA treatment, particularly with medications like methotrexate or biologics, can increase the risk of skin issues, and regular monitoring is important for early identification.

E. Watch for gastrointestinal upset with medication administration: NSAIDs like ibuprofen, which the client is taking for pain, can cause gastrointestinal issues such as ulcers or irritation. Monitoring for these symptoms is important to avoid complications related to the medication.

F. Discuss body image feelings with a trusted friend or therapist: The chronic nature of RA, along with potential joint deformities and limitations, can impact body image. Discussing these feelings with a trusted person or therapist can help the client manage the psychological aspects of living with a chronic condition.

G. Avoid fluids, to decrease trips to the bathroom: Reducing fluid intake could lead to dehydration, which may cause other complications. The client should be encouraged to drink adequate fluids, despite more frequent trips to the bathroom, to stay properly hydrated.

H. Prioritize rest, with short periods of activity: RA can cause joint fatigue and pain. It’s important to balance periods of rest with light, non-strenuous activities to reduce stress on the joints while maintaining some level of mobility. This can help manage energy levels and minimize joint strain.

A. Report any increase in the white blood cell count. B. Change the surgical dressing readily when soiled. C. Instruct the family to adhere to contact precautions. D. Wear a face mask while performing wound care.

Correct Answer is C

Explanation

A. Report any increase in the white blood cell count: While monitoring for signs of infection is important, an increase in WBC count alone does not address the risk of MRSA recurrence in the wound. Early intervention with infection control measures is more important.

B. Change the surgical dressing readily when soiled: Changing the dressing when soiled is necessary for wound hygiene but does not target MRSA recurrence. Adhering to infection control measures, like contact precautions, is more effective in preventing MRSA.

C. Instruct the family to adhere to contact precautions: Educating the family on contact precautions is critical for preventing the spread and recurrence of MRSA, especially in the postoperative period. It reduces the risk of contamination and protects both the patient and healthcare workers.

D. Wear a face mask while performing wound care: Wearing a face mask is not necessary for preventing MRSA transmission in the wound care setting. Contact precautions, including proper hand hygiene and wearing gloves, are more effective for MRSA prevention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.

Correct Answer is ["C","D","E","F","H"]

Explanation

Correct Answer is C

Explanation

Exhibits The nurse is preparing the client's plan of care. A major component of the clients at home care is pain management. Select the 3 most important interventions the nurse can educate the client with rheumatoid arthritis (RA) about to help with pain management.

Exhibits Choose the most likely options for the information missing from the statements by selecting from the lists of options provided. The nurse monitors the client's dropdownafter administering the morphine. The nurse should include dropdownto reduce complications of the client's injury.

Exhibits After the obstetrician leaves, the client appears confused and asks the nurse, "How will I know if I have high blood sugar?" Which are the nurse's best responses? Select all that apply.

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?