A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
Identify support groups in the community for long-term treatment.
Assist the client to identify negative effects of chemical dependency.
Determine the presence and degree of suicidal risk.
Refer client to mental health care provider for evaluation and treatment.
The Correct Answer is C
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
The elderly tend to heal more slowly which can delay wound healing and increase the risk of infection. The elderly person has a greater proportion of body surface area per amount of body mass which increases the amount of skin available for injury, and thus the severity of the burn. The elderly person has less physiological reserves which makes it more difficult for the body to respond to injury and stress. Elderly patients have comorbidities such as diabetes, cardiovascular disease, and respiratory disease that can impair the body's ability to heal and increase the risk of complications. Elderly patients do not typically have thicker skin as it thins with age.
Correct Answer is C
Explanation
The parents report that the child injured herself by falling off the couch.
A spiral fracture is a type of broken bone that occurs when a twisting force is applied to the bone. It is often seen in cases of child abuse, where the abuser grabs and twists the child's arm or leg.
Choice A is not correct because bringing the child to the facility soon after the injury does not rule out abuse. The abuser may have done so to avoid suspicion or to prevent further complications.
Choice B is not correct because crying when the arm is examined is a normal reaction for a child who is in pain and scared. It does not indicate abuse or neglect.
Choice C is correct because it is unlikely that a fall from a couch would cause a spiral fracture of the ulna and radius. These bones are strong and require a lot of force to break. A fall from a couch would more likely cause a greenstick fracture, which is a partial break of the bone that occurs in children with flexible bones.
Choice D is not correct because a single injury does not exclude abuse. The child may have been abused before and healed without medical attention, or the abuser may have targeted only one part of the body. A single injury should still raise suspicion and prompt further investigation.
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