A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

Anxiety as evidenced by abdominal complaints secondary to depression.

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

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

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

Answer and Explanation

The Correct Answer is D

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

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Correct Answer is C

Explanation

Regular exercise is a vital component of managing type 2 diabetes. It helps to lower blood glucose levels, improve insulin sensitivity, and increase HDL (the "good" cholesterol) levels. However, it is important for the client to obtain medical approval before starting or modifying an exercise regimen. The healthcare provider can assess the client's overall health status and provide specific recommendations regarding the type, duration, and intensity of exercise suitable for the client's individual needs and any potential limitations.

Limiting calories on days unable to exercise is a valid strategy for managing weight and blood glucose levels; however, it is not specifically related to increasing HDL levels. It is important to maintain a balanced and healthy diet overall.

Monitoring blood glucose levels daily is an important self-care practice for individuals with diabetes, but it is not specifically focused on increasing HDL levels. Blood glucose monitoring helps to assess the effectiveness of diabetes management and make necessary adjustments to medication, diet, or exercise.

Monthly appointments with the dietitian can be beneficial for diabetes management, as dietary modifications play a significant role. However, the instruction regarding exercise is more directly related to increasing HDL levels, and the frequency of appointments with the dietitian may vary based on individual needs and goals.

A. Reason for taking the aspirin. B. Dosage of ibuprofen taken. C. Presence of gastric pain. D. Amount of pain control.

Correct Answer is A

Explanation

The information that the nurse should obtain from the client first is: Reason for taking the aspirin.

It is important to first understand why the client was taking aspirin in order to determine the potential implications of switching to ibuprofen. Aspirin and ibuprofen are both nonsteroidal anti-inflammatory drugs (NSAIDs), but they have different indications and effects. Aspirin is commonly used for its antiplatelet properties to reduce the risk of heart attacks and strokes, while ibuprofen is primarily used for its analgesic and anti-inflammatory properties.

By understanding the reason for taking aspirin, the nurse can assess if the client was using it for its antiplatelet effects, which is important information to consider for the client's overall health and well-being.

Once the reason for taking aspirin is determined, the nurse can proceed to inquire about the other relevant information, such as the dosage of ibuprofen taken, presence of gastric pain, and amount of pain control. These details will help in assessing the client's current medication regimen, potential side effects or complications, and overall pain management.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is C

Explanation

The nurse is caring for a client who reports running out of aspirin 1 week ago and taking ibuprofen as a replacement. Which information should the nurse obtain from the client first?

Correct Answer is A

Explanation

A client with leukemia who is receiving myelosuppressive chemotherapy has a platelet count of 25,000/mm3 (25 x 109/L). Which intervention is most important for the nurse to include in this client's plan of care? Reference Range: Platelet Count [150,000 to 400,000/mm3 (156 400 x 109/L)]

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client Indicates that the teaching was effective?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

The home care nurse provided self-care instructions for a client with chronic venous insufficiency caused by deep vein thrombosis. Which instruction(s) should the nurse include in the client's discharge teaching plan? (Select all that apply.)

The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and scaly, and the mother reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?