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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.

Rationale:

A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:

Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.

B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:

A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.

C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:

Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.

D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:

While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.

A. "It's okay to feel afraid. Let's talk about what you are afraid of." B. "Your doctor is a great surgeon. You will be fine." C. "Don't worry. The important thing is you have now quit smoking." D. "I understand your fears. I was a smoker also."

Correct Answer is A

Explanation

The nurse should acknowledge and validate the client's feelings by saying, "It's okay to feel afraid. Let's talk about what you are afraid of." This response demonstrates empathy and encourages the client to express their concerns and feelings.

Choice B, "Your doctor is a great surgeon. You will be fine," dismisses the client's feelings and may increase their anxiety.

Choice C, "Don't worry. The important thing is you have now quit smoking," minimizes the seriousness of the procedure and the client's potential risks.

Choice D, "I understand your fears. I was a smoker also," shifts the focus from the client to the nurse and is not an effective way to provide emotional support for the client.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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