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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Emphasize that using safe sex practices removes the risk of STIs: While safe sex practices significantly reduce the risk of STIs, they do not eliminate the risk entirely. It is important to provide accurate, non-judgmental information about risk reduction rather than implying complete protection.

B. Remain non-judgmental and assure the client of confidentiality: The nurse should provide a safe, supportive environment to encourage open communication, while assuring the client that their information will remain confidential. This promotes trust and encourages the client to seek necessary care.

C. Clarify that all STIs are transmitted through sexual intercourse: While many STIs are transmitted through sexual contact, some can also be transmitted through other routes, such as blood or vertical transmission.

D. Inform that follow-up may end after the treatment is finished: Follow-up care ensures the effectiveness of treatment and monitoring for potential complications. Informing the client that follow-up may end prematurely could discourage the client from seeking necessary care.

A. Clarify end of life desires. B. Offer sips of favorite beverages. C. Initiate comfort measures. D. Prepare for emergent oral intubation.

Correct Answer is C

Explanation

A. Clarify end of life desires: While understanding a client’s goals is vital, this may not address her immediate needs. The client is already showing signs of distress and hypoxia, so initiating comfort measures promptly is more urgent than discussing future preferences.

B. Offer sips of favorite beverages: Offering fluids may help with oral comfort but does not address the client’s respiratory distress or overall suffering. It is a low-priority intervention in the setting of acute hypoxia and confusion related to terminal illness.

C. Initiate comfort measures: Comfort measures are the priority for a terminally ill client with hypoxia and confusion who is refusing food and expressing a wish to go home. This aligns care with the client's likely stage in the dying process and ensures symptom relief over aggressive interventions.

D. Prepare for emergent oral intubation: Intubation is invasive and likely inconsistent with palliative goals in end-stage cancer. Without clear patient consent or indication that life-prolonging measures are desired, focusing on comfort is more appropriate and ethical.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with the sexually transmitted infection (STI) syphilis. The client reports having sex with someone who had many partners. Which response should the nurse provide?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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