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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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Incorrect - Encouraging the use of ice on the areola is not a recommended intervention for addressing inverted nipples and promoting successful breastfeeding.
B) Incorrect - Teaching about the use of a breast pump might be useful for milk expression but may not directly address the issue of latching due to inverted nipples.
C) Incorrect - Offering supplemental formula feedings does not address the underlying issue of inverted nipples and breastfeeding difficulties.
D) Correct-inverted nipples can make breastfeeding challenging as the baby may have difficulty latching directly onto the breast. A breast shield can be recommended to help draw out the nipple and create a more optimal shape for latching. It can also provide a larger surface area for the baby to grasp onto, making breastfeeding more successful for both the mother and the baby.

A. 0200 B. 1300 C. 1000 D. 1600 E. 1400 F. 0900 G. 0800 H. 0500 I. 1100 J. 1200

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

Explanation

A. Incorrect- 0200: This is not a scheduled time for vital sign assessments every 4 hours.

B. Correct- 1300: This is 4 hours after the 0900 vital signs, following the every 4-hour schedule.

C. Correct 1000: This is 4 hours after the 0600 vital signs, following the every 4-hour schedule.

D. Correct 1600: This is 4 hours after the 1200 vital signs, following the every 4-hour schedule.

E. Correct 1400: This is 4 hours after the 1000 vital signs, following the every 4-hour schedule.

F. Correct 0900: This is the initial vital sign assessment upon admission to the trauma unit at 0100, and it's also 4 hours after the 0500 vital signs.
G. Correct 0800: This is 4 hours after the 0400 vital signs, following the every 4-hour schedule.

H. Incorrect 0500: This is 3 hours after the initial vital sign assessment at 0100. The scheduled assessments are every 4 hours, so the nexta one would be at 0900.
I. Correct 1100: This is 4 hours after the 0700 vital signs, following the every 4-hour schedule.

J. Correct 1200: This is 4 hours after the 0800 vital signs, following the every 4-hour schedule.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is one day postpartum tells the nurse that her baby cannot latch onto the breast. The nurse determines that the client's nipples are inverted. Which action should the nurse implement?

Correct Answer is D

Explanation

Exhibits In the trauma unit, vital signs ordered every 4 hours are taken at 0400, 0800, 1200, 1600, 2000, and 2400. Select the times that the nurse should do vital signs. Select all that apply.

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

Explanation

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother because he has a fever and an earache. During the assessment, the mother asks the nurse why her child is at the 5th percentile for weight and height for his age. Which response is best for the nurse to provide?

In planning care for a client with early stage Alzheimer's disease, the nurse establishes the nursing problem of risk for injury related to impaired judgment. Which intervention is most important for the nurse to include in this client's plan of care?

The nurse is caring for a client admitted with an acute exacerbation of chronic obstructive pulmonary disease (COPD) who reports a pounding headache. Which action should the nurse take?

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?