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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct- Viral meningitis is an inflammation of the meninges (the protective membranes surrounding the brain and spinal cord) caused by a viral infection. While it can be serious, it is generally less severe than bacterial meningitis. Monitoring the client's temperature is an important aspect of care, as changes in temperature can indicate the progression of the illness or the effectiveness of interventions. A temperature increase from 101°F to 102°F is a subtle change but may still require close monitoring and symptom management. The practical nurse (PN) is capable of monitoring vital signs, including temperature, and reporting any changes to the registered nurse (RN) or healthcare provider. It is within the PN's scope of practice to assess and report changes in vital signs and general condition. The other scenarios involve more complex clinical situations that may require the expertise of registered nurses.
B) Incorrect- Myxedema coma is a severe form of hypothyroidism and is considered a medical emergency. Managing and assessing a client with myxedema coma requires advanced assessment, critical thinking, and interventions that are typically within the scope of registered nurses.
C) Incorrect- Diabetic ketoacidosis (DKA) is a complex condition that requires frequent monitoring of blood glucose levels, electrolytes, vital signs, and assessment of the level of consciousness. The change in the Glasgow Coma Scale score indicates a neurological deterioration that requires immediate attention and intervention, making it suitable for a registered nurse.
D) Incorrect- A subdural hematoma is a serious neurological condition that requires close monitoring of vital signs and neurological status. The change in blood pressure indicates a potential change in intracranial pressure and should be managed by registered nurses with expertise in neurological care.
Correct Answer is ["A","B","D","F"]
Explanation
A.Correct- The nurse should provide the parents with the phone numbers and websites of local organizations that offer support and counseling for families who have experienced a traumatic event. The nurse should also encourage the parents to seek professional help if they feel overwhelmed, depressed, or anxious.
B.Correct- Educating the parents about pool safety is crucial to prevent future accidents. This information can include guidelines for supervision, barriers, and measures to prevent drowning incidents.
C.Incorrect- While it's important for parents to be aware of the seriousness of child neglect, including this information in pre-discharge education might not be the most appropriate time, especially if the child is showing only minor signs of impact from the incident. This could increase their guilt and distress and damage the therapeutic relationship. The nurse should focus on providing support and education, not judgment or punishment.
D.Correct- The nurse should advise the parents to schedule a follow-up visit with the child's pediatrician within a week of discharge. The nurse should explain that the pediatrician will monitor the child's recovery and check for any signs of complications, such as brain damage, infection, or lung injury.
F. Correct- Assessing the parent's coping skills can help identify if they are dealing with any emotional stress or trauma related to the incident. Providing appropriate support or referrals if needed can be beneficial.
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