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
To monitor for adverse effects from prasugrel, a platelet inhibitor, the nurse should prioritize assessing for bleeding or abnormal bleeding tendencies. Therefore, observing the color of urine is the most important assessment among the options provided.
Changes in urine color, such as the presence of blood or dark-colored urine, can indicate internal bleeding or bleeding in the urinary tract, which can be a potential adverse effect of platelet inhibitors. It is crucial to monitor for signs of bleeding to ensure the client's safety and intervene promptly if necessary.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: Misplacing car keys occasionally is a common occurrence and may not necessarily indicate Alzheimer's disease. It can happen to anyone, especially when distracted or in a hurry.
Choice B rationale: Difficulty performing familiar tasks, such as cooking a meal or driving to a familiar location, is an early warning sign of Alzheimer's disease. It indicates changes in cognitive function.
Choice C rationale: Losing sense of time, such as not knowing the date, day of the week, or season, can be an early indicator of Alzheimer's disease. It reflects impairments in temporal orientation.
Choice D rationale: Problems with performing basic calculations, such as managing finances or following a recipe, are early signs of Alzheimer's disease. It shows a decline in cognitive abilities related to numbers and problem-solving.
Choice E rationale: Becoming lost in a usually familiar environment, such as getting disoriented in one's own neighborhood, is a significant early warning sign of Alzheimer's disease. It suggests spatial and memory impairments.
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