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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

"Repeat the dose if your child vomits within 1 hour after taking the medication." This statement is incorrect. If a child vomits within 1 hour after taking digoxin, the parents should not repeat the dose. The reason is that the child may have already absorbed a sufficient amount of the medication before vomiting, and an additional dose could lead to digoxin toxicity.

Choice B reason:

"You can add the medication to a half-cup of your child's favourite juice." This statement is incorrect. Adding digoxin to juice or any other food or drink is not recommended. Digoxin should be administered separately and not mixed with food or liquids to ensure accurate dosing and prevent potential interactions with other substances.

Choice C reason:

"Have your child drink a small glass of water after swallowing the medication." This statement is correct. Giving a small glass of water after administering digoxin helps ensure that the medication is fully swallowed and goes into the stomach, reducing the risk of it being retained in the mouth or throat.

Choice D reason:

"Limit your child's potassium intake while she is taking this medication." This statement is not accurate. Digoxin is often prescribed in conjunction with other heart failure medications, some of which may impact potassium levels. However, the parents should not arbitrarily limit the child's potassium intake without specific instructions from the healthcare provider. The healthcare provider will monitor the child's potassium levels and adjust the treatment plan as necessary.

A. Document the infiltration. B. Stop the infusion. C. Elevate the arm. D. Apply a warm compress.

Correct Answer is B

Explanation

The correct answer is B.

Stop the infusion. The nurse should stop the infusion immediately to prevent further fluid accumulation and tissue damage. This is a priority action accordingto the ABCDE principle, which guides nurses to prioritize airway, breathing, circulation, disability, and exposure issues. Infiltration is a complication of IV therapy that occurs when fluid leaks into the surrounding tissue due to dislodgment or puncture of the catheter. The signs and symptoms of infiltration include edema, coolness, pallor, pain, and decreased flow rate at the insertion site.

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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 providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the followingactions should the nurse take first?

Correct Answer is B

Explanation

A nurse in a provider's office is reinforcing teaching about cigarette smoking with a client.Which of the following adverse effects should the nurse include in the teaching?

A nurse is assessing the peripheral catheter insertion site of a client who is receiving an infusion. The nurse notices redness and warmth to the touch around the insertion site. The nurse should document the finding as which of the following complications?

A nurse is reinforcing teaching with a client who has a new prescription for albuterol PRN. The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

A nurse is caring for a client who has a recent diagnosis of a terminal illness. The nurse should identify which of the following as an indication of hopelessness?

A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

A nurse is collecting data from a client. The nurse should identify that which of the following manifestations is an indication of a candida infection?

A nurse in a long-term care facility is delegating care for a group of clients for the oncoming shift. Which of the following tasks should the nurse delegate to an assistive personnel? (Select all that apply.)