A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

Hypotension

Increased cognitive awareness

Viral infection

Increased energy

Answer and Explanation

The Correct Answer is C

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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Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

A. Identify the use of defense mechanisms. B. Prevent the client from harming herself or others. C. Support the client's coping skills.

Correct Answer is B

Explanation

Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.

Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.

Choice C, supporting the client's coping skills, is not a priority intervention.

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A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

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