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 B
Explanation
Answer: B. Cloudy dialysate outflow.
Rationale:
A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.
B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.
C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.
D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.
Correct Answer is C
Explanation
Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.
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