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 {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
The client's symptoms are concerning for angina or a possible myocardial infarction (heart atack) and require immediate intervention. Nitroglycerin is a medication that can help relieve chest pain associated with cardiac events by dilating blood vessels and reducing the workload on the heart.
Therefore, the nurse should administer nitroglycerin as ordered by the provider. After administering nitroglycerin, the nurse should obtain an ECG to assess for any changes in cardiac rhythm or evidence of ischemia (lack of blood flow to the heart muscle).
The ECG can provide important diagnostic information and guide further treatment decisions.
Correct Answer is A
Explanation
Choice A Reason:
The shortness of breath is correct. Albuterol is a bronchodilator medication commonly used to relieve symptoms of shortness of breath and wheezing in individuals with conditions such as asthma or chronic obstructive pulmonary disease (COPD). It helps to relax the muscles in the airways, allowing for easier breathing. It is not used to treat swelling of the lips, nausea, or hyperglycemia.
The other choices are not the answer because albuterol is specifically indicated for the treatment of respiratory symptoms like shortness of breath and wheezing associated with conditions like asthma or COPD. Here's why the other options are not correct:
Choice B Reason:
Swelling of the lips is incorrect. Albuterol is not used to treat lip swelling. Lip swelling may be related to allergies or other medical conditions, and treatment would depend on the underlying cause.
Choice C Reason:
Nausea is incorrect. Albuterol is not used to treat nausea. Nausea can have various causes, and treatment would depend on the underlying reason for the nausea.
Choice D Reason:
Hyperglycemia is incorrect. Albuterol does not treat hyperglycemia (high blood sugar). It is used for respiratory symptoms, not for managing blood sugar levels. Treatment for hyperglycemia typically involves medications such as insulin or oral antidiabetic agents, as well as dietary and lifestyle changes.
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