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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?

A.

Anxiety as evidenced by abdominal complaints secondary to depression.

B.

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

C.

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

D.

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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Related Questions

Correct Answer is ["9"]

Explanation

Here are the steps you can follow to calculate the infusion pump flow rate:

Step 1: Calculate the prescribed dose in mcg/min

  1. Dose per weight: 2 mcg/kg/min * 60 kg = 120 mcg/min

Step 2: Convert the concentration in the IV bag to mcg/mL

  1. Convert mg to mcg: 200 mg * 1000 mcg/mg = 200,000 mcg
  2. Concentration: 200,000 mcg / 250 mL = 800 mcg/mL

Step 3: Calculate the flow rate in mL/min

  1. Flow rate: 120 mcg/min / 800 mcg/mL = 0.15 mL/min

Step 4: Convert the flow rate to mL/hour

  1. Hour conversion: 0.15 mL/min * 60 min/hour = 9 mL/hour

Therefore, the nurse should program the infusion pump to deliver 9 mL/hour.

Correct Answer is C

Explanation

A) Incorrect- While physical soothing can help comfort the child after the injections, it may not significantly reduce the duration of pain during the injections themselves.
B) Incorrect- Verbal reassurance is important to provide a calming environment, but it may not directly reduce the duration of pain during the injections.
C) Correct- Administering vaccines can be distressing for toddlers due to the pain associated with injections. To reduce the duration of pain and minimize the overall discomfort, the nurse should prioritize the strategy of simultaneous injections. This involves administering multiple vaccines at the same time rather than spacing them out. The rationale behind this approach is that the child experiences the discomfort of the injections only once, which can help reduce their overall distress and anxiety.
D) Incorrect- The positioning of the child may not have a direct impact on the duration of pain during injections. However, choosing an appropriate position for comfort is still important.

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