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 C
Explanation
Choice A Reason:
Hypoglycemia (low blood sugar) is not a common adverse effect of atorvastatin.
Choice B Reason:
Daytime drowsiness is not a typical side effect of statin medications and is more commonly associated with other types of medications, such as sedatives or sleep aids.
Choice C Reason:
Muscle pain is correct. The nurse should instruct the client to monitor and report muscle pain (myalgia) to the healthcare provider when taking atorvastatin. Myalgia is a potential adverse effect of statin medications, and in rare cases, it can progress to a more serious condition called rhabdomyolysis, which involves muscle breakdown and can lead to kidney damage. Therefore, any new or unexplained muscle pain, tenderness, or weakness should be reported promptly to the healthcare provider for evaluation.
Choice D Reason:
Palpitations (rapid or irregular heartbeats) are not commonly associated with atorvastatin use. If a client experiences palpitations, it may be related to other factors or conditions and should be evaluated separately.
Correct Answer is C
Explanation
Albuterol is a bronchodilator medication that is commonly delivered through a metered-dose inhaler (MDI) to treat asthma and other respiratory conditions. Proper inhaler technique is crucial for effective delivery of the medication to the lungs.
Option (a) is incorrect because the client should actually tilt their head back slightly and breathe out fully before inhaling the medication.
Option (b) is incorrect because the client should take a slow, deep breath in while depressing the canister once.
Option (d) is incorrect because the client should hold their breath for 10 seconds after inhaling the medication to allow it to reach the lungs.
Therefore, the correct instruction for the nurse to include in the teaching is to instruct the client to close their mouth around the mouthpiece of the inhaler to ensure that the medication is delivered directly to the lungs.
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