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

Answer and Explanation

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.

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Correct Answer is B

Explanation

An incident report is formal documentation used to report any unexpected or adverse events that occur during the course of patient care. It provides a record of the incident and helps identify areas for improvement in patient safety and quality of care. The incident report should include details about the error, the potential impact on the client, actions taken to address the error, and any necessary follow-up.

A nursing care plan is a document that outlines the client's nursing diagnoses, goals, interventions, and evaluations. It is not the appropriate place to document a medication error or incident.

The provider's progress notes are documentation made by the healthcare provider, typically documenting their assessments, diagnoses, treatment plans, and progress of the client. A medication error made by the nurse should not be documented in the provider's progress notes.

The controlled substance inventory record is a record used to track the dispensing and administration of controlled substances. While it is important to maintain accurate records of controlled substances, documenting a medication error in this record is not the appropriate place as it is primarily used for inventory management purposes

A. Encourage the client to bathe frequently. B. Apply powder to the client's skin. C. Add moisturizing oil to the client's bath water. D. Place a humidifier in the client's room.

Correct Answer is D

Explanation

Effleurage is a massage technique commonly used during labor to provide comfort and relaxation. It involves using gentle, rhythmic stroking movements on the abdomen during contractions. This technique can help relieve tension, promote relaxation, and provide distraction from the intensity of the contractions.

Deep breathing techniques are often used during labor to promote relaxation and manage pain. However, this instruction does not specifically relate to effleurage.

Focusing on an object in the room, such as a focal point, can be a helpful technique during labor to redirect attention and manage pain. However, this instruction does not specifically relate to effleurage.

Applying pressure to the sacral area can help alleviate back pain during labor. However, this instruction describes the use of a tennis ball and is not specifically related to effleurage.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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