The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old
She and her father were the only survivors of the crash. She is seeking care for depression.
Click to highlight the areas that the nurse should react to immediately.
The client has returned to work at an accounting firm and has started going to a grief support group. She states she is seeking care from a healthcare professional because her father is worried about her. The client states she only gets 2-3 hours of sleep due to nightmares about the crash.
She states that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy after the accident, especially when she is in the car. She also stated, " feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.
she only gets 2-3 hours of sleep due to nightmares about the crash
She feels that she is "jumpy after the accident
especially when she is in the car
feel so sad that I can't seem to feel anything at all
The Correct Answer is ["A","B","C","D"]
Insufficient sleep, particularly due to nightmares, can exacerbate depression and should be addressed promptly.
Feeling "jumpy" or experiencing heightened anxiety, especially in situations reminiscent of the trauma, indicates a possible post-traumatic stress disorder (PTSD symptom.
A profound sense of sadness and numbness can be indicative of severe depression, requiring immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The presence of clear, pale red liquid drainage from the rectal tube suggests possible bleeding or other issues that need prompt assessment, making this client a priority.
B. Dark red drainage on a postoperative dressing could indicate bleeding, which requires immediate attention to assess the extent of bleeding and intervene accordingly.
C. Clients with compressed Jackson-Pratt drains may not have adequate drainage, potentially leading to complications such as hematoma or infection if the drain becomes obstructed.
However, since the bulb is compressed, indicating no active drainage, this client can be assessed later.
D. A distended abdomen with no drainage from the nasogastric tube could indicate a bowel obstruction or other gastrointestinal issue requiring urgent assessment, making this client a priority for assessment.
Correct Answer is C
Explanation
A. Notify the emergency response team of the client's seizure: While the seizure is significant, it lasted less than 1 minute and resolved spontaneously. There is no need to call an emergency response team unless complications arise or the seizure becomes prolonged.
B. Keep orienting the client to time and space until he is less confused: While supportive, this is not the priority. Postictal confusion is expected and does not usually require active reorientation until the client regains baseline status.
C. Explain the postictal state that usually follows seizures: Providing reassurance and education to the spouse about postictal symptoms (such as confusion, lethargy, and altered responsiveness) is appropriate and therapeutic. It addresses her concern while monitoring the client for further changes.
D. Ask the wife to wait outside the room until the nurse can talk with her: This action excludes the spouse unnecessarily and delays communication. Involving the family promotes trust and understanding.
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