A nurse on a mental health unit is caring for a client.
Complete the following sentence by using the lists of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Rationale for correct choices
• Thoughts of self‑harm: The client recently experienced multiple major stressors, loss of a job and the end of a long-term relationship, while displaying flat affect, tearfulness, withdrawal, and refusal to eat. These changes, combined with the statement, “My life is a mess,” indicate worsening depression and internal distress. These findings elevate the risk for self‑harm and require immediate monitoring.
• Hopelessness: The client’s statements reflect feelings of worthlessness and an inability to see a path forward, which are hallmark signs of hopelessness. Their withdrawal, refusal to eat, and persistent tearfulness reinforce that they are overwhelmed and unable to cope with current stressors. Hopelessness is closely linked with suicidal ideation, explaining the elevated self‑harm risk.
Rationale for incorrect choices
• Anorexia nervosa: Although the client is refusing meals, this refusal occurs in the context of emotional distress rather than weight‑loss motivation or body‑image disturbance. The client’s BMI is low but not critically low, and there is no fear of gaining weight or distorted self‑perception. Appetite changes are common in depression and better explained by mood not eating disorders.
• Acute dystonic reaction: Acute dystonia is associated with antipsychotic medications, not sertraline, which the client is currently taking. No signs such as muscle spasms, stiff neck, or oculogyric crisis are present. The client’s symptoms are emotional and cognitive, not neuromuscular.
• Refusal to eat: While refusal to eat is concerning, it alone does not most strongly indicate risk for self‑harm. Poor appetite is common in depression and may reflect low motivation or energy. It lacks the direct emotional connotation that hopelessness carries in predicting self‑harm.
• Family history: A family history of major depressive disorder increases long‑term vulnerability but does not explain the client’s immediate risk situation. The client’s current behaviors and statements provide more immediate clinical evidence than hereditary factors. Family history does not sufficiently reflect the acute emotional state contributing to self‑harm risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Have you noticed a rash or reddening of your skin?": While skin irritation can occur with some occupational exposures, insulation installers are more commonly exposed to airborne fibers that affect the respiratory system rather than causing primary skin rashes.
B. "Do you have a cough or any breathing problems?": Insulation installers are at risk for inhaling fiberglass, asbestos, or other particles that can irritate the lungs and airways. Assessing for respiratory symptoms is essential to identify potential occupational lung disease or irritation.
C. "Have you noticed any loss of hearing or ringing in your ears?": Hearing loss and tinnitus are more relevant for workers exposed to loud noise, such as in manufacturing or construction environments with heavy machinery, rather than insulation installation specifically.
D. "Do you have any numbness or tingling in your fingers?": Numbness or tingling is usually associated with repetitive motion injuries, neuropathies, or exposure to vibrating tools. While possible, it is less directly related to the primary occupational hazards of insulation work.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Rationale for correct choices
• Seizures: The client presents with severe hypertension (BP 162/112 mm Hg and 166/110 mm Hg), +3 pitting edema, and proteinuria (3+), which are classic indicators of severe preeclampsia. These factors place the client at high risk for eclampsia, which manifests as seizures during pregnancy. Close monitoring and early intervention are critical to prevent maternal and fetal complications.
• Placental abruption: Severe hypertension and preeclampsia increase the risk of placental abruption, a condition in which the placenta separates prematurely from the uterine wall. This can compromise fetal oxygenation and lead to significant maternal bleeding. The client’s elevated blood pressure, edema, and decreased fetal movement indicate a higher likelihood of this obstetric emergency.
Rationale for incorrect choices
• Heart failure: Although hypertension and fluid shifts in preeclampsia can strain the heart, there is no current evidence of pulmonary edema, dyspnea, or heart failure symptoms in this client. Heart failure is a less immediate risk compared with seizures and placental abruption in the context of severe preeclampsia.
• Hypoglycemia: There is no indication of low blood glucose in the client; laboratory results show glucose within normal limits (85 mg/dL). Hypoglycemia is not a typical complication of preeclampsia and is therefore not an immediate concern in this scenario.
• Cervical insufficiency: Cervical insufficiency typically presents earlier in gestation with painless dilation and risk of preterm birth, rather than in a 31-week client with hypertensive complications. The client’s symptoms of headache, edema, and proteinuria do not indicate cervical insufficiency.
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