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 D
Explanation
Choice A Reason:
Limiting fluid intake to 750 mL per day is not recommended, as adequate hydration is essential for overall health. The client should maintain good hydration unless specifically advised otherwise by their healthcare provider.
Choice B Reason:
Cleansing the neck by rubbing with a washcloth may be too harsh for the irradiated skin. The skin in the radiation field can become sensitive and may require gentle cleansing with mild soap and patting dry, rather than rubbing.
Choice C Reason:
Eating three large meals each day may not be suitable for all clients undergoing radiation therapy, especially if they are experiencing side effects such as difficulty swallowing or changes in taste. Dietary recommendations should be individualized based on the client's specific needs and symptoms. Smaller, more frequent meals may be more manageable for some clients.
Choice D Reason:
Avoiding exposing the neck to the cold is correct. When providing instructions to a client undergoing radiation therapy to the neck, it's important to emphasize the need to protect the treated area from extreme temperature changes. Exposure to cold temperatures can cause vasoconstriction and potentially lead to tissue damage in the irradiated area. Therefore, advising the client to avoid exposing the neck to cold is a vital precaution.
Correct Answer is C
Explanation
Choice A Reason:
8 lb is not an appropriate weight gain for this client because it falls below the recommended range.
Choice B Reason:
32 lb is excessive weight gain for a client with a prepregnancy BMI of 30.5. Excessive weight gain during pregnancy can increase the risk of various complications, including gestational diabetes, hypertension, and larger-than-average birth weight.
Choice C Reason:
16 lb is within the recommended range for weight gain during pregnancy for a client with a prepregnancy BMI of 30.5. This falls in the range of approximately 11 to 20 pounds (5 to 9 kilograms) of weight gain.
Choice D Reason:
24 lb is above the upper limit of the recommended weight gain range for a client with a prepregnancy BMI of 30.5. It exceeds the upper limit of approximately 20 pounds (9 kilograms) of weight gain.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today