A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Concentrate on and ventilate emotions when distressed.

Shift attention from self to the needs and requests of others.

Relax and reduce the amount of effort to solve the problem.

Focus on small achievable tasks, not taxing problems.

Answer and Explanation

The Correct Answer is D

Choice A Rationale:
While emotional expression and ventilation can be therapeutic, it may not be the most appropriate coping strategy for someone with depression who may already be overwhelmed by negative emotions. Ventilating emotions without a structured approach might not provide the desired relief and can even exacerbate feelings of distress.

Choice B Rationale:
This choice may not be suitable for someone with depression because it could lead to further neglect of their own needs and contribute to feelings of guilt or exhaustion.

Choice C Rationale:
While relaxation techniques can be helpful, reducing the effort to solve problems may not be the most effective strategy for individuals with depression. Avoidance of problems can perpetuate feelings of helplessness and hopelessness.

Choice D Rationale:
For a client with depression who is struggling with handling personal circumstances, focusing on small achievable tasks can be a helpful coping strategy. Breaking down larger problems into manageable steps can reduce feelings of overwhelm and gradually improve the client's sense of accomplishment and self-efficacy.

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Correct Answer is A

Explanation

Choice A Rationale:
Ecchymotic blood accumulations (bruises) are indicative of possible trauma or injury to the scalp. In this case, it suggests that the hair loss is likely due to physical manipulation (such as pulling or arranging the hair to cover bald spots) rather than a medical condition.

Choice B rationale:
This choice suggests that evidence of patches of lost hair would be indicative of non-disease-related hair loss. However, this is not necessarily true. Medical conditions, such as alopecia areata, can also cause patchy hair loss without physical trauma. Therefore, it is not a definitive indicator that hair loss is not disease-related.

Choice C rationale:
Episodic complaints of pruritus (itching) could be associated with various scalp conditions, including those that lead to hair loss. Itching alone does not rule out disease-related hair loss. In fact, some medical conditions can cause both itching and hair loss.

Choice D rationale:
Erythema (redness) of localized lesions may suggest inflammation but does not necessarily indicate non-disease-related hair loss. Medical conditions can also cause localized inflammation and hair loss.

A. Call and give a report immediately B. Administer loop diuretic C. Schedule for Hemodialysis immediately D. Check blood glucose level E. Draw a repeat potassium level F. Hold Lisinopril G. Administer insulin, dextrose 50%, and calcium gluconate. Then repeat 12 lead EKG

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

Explanation

Choice A rationale:
This is not a priority action for the nurse at this time. The nurse should first implement the ordered treatments for hyperkalemia and stabilize the client's condition before calling and giving a report to the receiving unit.

Choice B rationale:
Loop diuretics are medications that increase urine output and can lower potassium levels in mild cases of hyperkalemia. However, they are contraindicated in patients with ERSD who have oliguria or anuria (reduced or absent urine production). Loop diuretics can worsen renal function and fluid overload in these patients.

Choice C rationale:
Scheduling the client for hemodialysis is crucial, especially if the client has missed a scheduled dialysis session. Hemodialysis can help manage electrolyte imbalances and fluid overload.

Choice D rationale:
Checking the blood glucose level is important, especially in a client with a history of diabetes. Maintaining glycemic control is essential for overall health.

Choice E rationale:
Drawing a repeat potassium level is necessary to monitor the client's electrolyte status, especially given the ECG changes.

Choice F rationale:
Holding Lisinopril, an ACE inhibitor, is appropriate in this context, considering the client's elevated blood pressure and potential renal issues. It should be done under the guidance of the healthcare provider.

Choice G rationale:
Administering insulin, dextrose, and calcium gluconate can help manage hyperkalemia, which may be indicated by the ECG changes. Repeating the 12-lead EKG is important to assess the response to treatment and any changes in cardiac rhythm.

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A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

Correct Answer is A

Explanation

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

Explanation

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

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The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?