A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an Indication that the client is experiencing a crisis?
Client isolates themselves from their family and friends
Client reports intermittent depressed mood
Client reports a decreased appetite
Client expresses an inability to experience pleasure
The Correct Answer is A
Choice A Reason:
Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.
Choice B Reason:
Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.
Choice C Reason:
Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.
Choice D Reason:
Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Encouraging assertiveness helps the client build self-confidence and the ability to express their needs and preferences. Individuals with dependent personality disorder often struggle with making decisions and being overly reliant on others, so promoting assertiveness can be an important part of their therapeutic process.
Choice B Reason:
Assuming responsibility for making the client's decisions is not appropriate because it further reinforces dependency, which is not a healthy outcome for individuals with dependent personality disorder.
Choice C Reason:
Maintaining a verbal no-harm contract is a safety measure for clients at risk of self-harm but is not specific to dependent personality disorder and may not be the primary focus of discharge teaching for this condition.
Choice D Reason:
Limiting the client's social interactions is not advisable. Encouraging social interactions and support can be beneficial for individuals with dependent personality disorder, as long as they are not excessively reliant on others for decision-making and functioning.
Correct Answer is D
Explanation
After a tonic-clonic seizure, the nurse should first check the child for any injuries, particularly in the oral cavity. This is because during a seizure, the child's tongue may have been biten, or there may be other oral injuries. Therefore, it is essential to check the oral cavity for any injury or bleeding.
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