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 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.

A. Tell the client to discuss the medication side effects with the healthcare provider. B. Tell the client that the medication's side effects will most likely dissipate over time. C. Inform the client that gradual tapering must be used to discontinue the medication. D. Remind the client that feeling better is the therapeutic effect of the medication.

Correct Answer is C

Explanation

The correct answer is choice c. Inform the client that gradual tapering must be used to discontinue the medication.

Choice A rationale:

While discussing medication side effects with the healthcare provider is important, it does not address the immediate concern of discontinuing the medication safely. The nurse should provide guidance on the proper discontinuation process.

Choice B rationale:

Telling the client that side effects will most likely dissipate over time may not be accurate for all individuals and does not address the client’s desire to stop the medication.

Choice C rationale:

Informing the client that gradual tapering must be used to discontinue the medication is crucial. Abruptly stopping antidepressants can lead to withdrawal symptoms and a potential relapse of depression.

Choice D rationale:

Reminding the client that feeling better is the therapeutic effect of the medication is true, but it does not address the client’s concern about discontinuing the medication safely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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