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 reports a decreased appetite
Client isolates themselves from their family and friends
Client expresses an inability to experience pleasure
Client reports intermittent depressed mood
The Correct Answer is B
Answer: B. Client isolates themselves from their family and friends
Rationale: A crisis is a situation that overwhelms a person's usual coping mechanisms and causes psychological distress. A client who isolates themselves from their family and friends is showing a sign of impaired social functioning, which indicates a crisis. The other options are not specific to a crisis and could be manifestations of anxiety or depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Observe the client during and after meals. Bulimia nervosa is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The nurse should monitor the client for signs of purging, such as frequent trips to the bathroom, and provide support and supervision during and after meals to prevent this behavior . This is a priority intervention that addresses the client's physical health and safety.
Correct Answer is C
Explanation
The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.
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