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
This statement should be included in the change-of-shift report because it provides vital information about the patient’s condition and any changes that have occurred to the patient during the shift.
Statement B is wrong because it does not provide relevant information about the patient’s current condition or changes that have occurred during the shift. Statement C is wrong because it does not provide relevant information about the patient’s medical condition. Statement D is wrong because it does not provide new information about changes that have occurred during the shift.
Change-of-shift reports are key to inpatient care because they provide vital information about and responsibility for the patient from the off-going provider to the on-coming provider.
Correct Answer is C
Explanation
Choice A Reason:
Supine is incorrect. The supine position (lying flat on the back) is not the best choice because it can increase the risk of airway obstruction and discomfort, especially if there is swelling or drainage from the surgical site.
Choice B Reason:
Left lateral is incorrect. The left lateral position (lying on the left side) is not typically used after a thyroidectomy because it does not provide the same advantages for airway management, swelling reduction, and comfort as the semi-Fowler's position.
Choice C Raeson:
Semi-Fowler's position is the most appropriate choice for a client who is postoperative following a subtotal thyroidectomy for several reasons:
Airway Management: Elevating the head of the bed in a semi-Fowler's position helps maintain airway patency and reduces the risk of airway obstruction or compression of the surgical site, which is important for respiratory comfort and function.
Swelling and Drainage: After thyroid surgery, there may be swelling and drainage from the surgical site. The semi-Fowler's position can assist in reducing swelling and facilitating proper drainage.
Comfort: This position generally provides greater comfort for the client, especially when there may be discomfort or soreness at the surgical site.
Choice D Reason:
Dorsal recumbent is incorrect. The dorsal recumbent position (lying on the back with knees flexed and feet flat on the bed) is also not the most appropriate choice for post-thyroidectomy care because it does not offer the same benefits as the semi-Fowler's position in terms of airway management, swelling reduction, and comfort.
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