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
Explanation
Blood-tinged dialysate outflow.
The nurse should report any presence of blood in the dialysate immediately to the provider, as it could indicate injury to the peritoneal membrane and the need for further evaluation. The presence of blood in the outflow may also indicate serious hemorrhage or trauma.
Option B, cloudy dialysate, can be a sign of infection, but it is not an immediate concern.
Option C, dialysate leakage during inflow, may indicate a problem with the catheter, but it can usually be managed by repositioning the patient.
Option D, discomfort during dialysate inflow, is a common occurrence and can be managed with analgesics or other supportive measures.
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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