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. Blood alcohol level of 0.09% (90 mmol/L): Although an elevated blood alcohol level could contribute to slurred speech and unsteady gait, the client's clinical presentation is more consistent with lithium toxicity rather than alcohol intoxication. However, it's important to assess for recent alcohol consumption and potential interactions with medications.
B. Six hours of sleep in the past three days: Sleep disturbances are common in bipolar disorder, but in this scenario, the more concerning issue is the potential lithium toxicity, as indicated by the client's symptoms.
C. Serum lithium level of 1.6 mEq/L (1.6 mmol/L): Correct! A serum lithium level above the therapeutic range (greater than 1.2 mEq/L) can lead to adverse effects such as slurred speech, ataxia, and tremors. This finding indicates lithium toxicity and requires immediate intervention.
D. Weight loss of 10 pounds (4.5 kg) in past month: Weight changes can be a concern in bipolar disorder, but in this case, the symptoms are more suggestive of lithium toxicity rather than related to weight loss
Correct Answer is ["A","B","D","E"]
Explanation
A. Confusion can be a sign of a concussion or other injury resulting from a fall, which is a common risk for individuals with Parkinson's disease.
B. Reviewing the client's current food and medication allergies is important as allergies can contribute to confusion if the client is exposed to an allergen.
C. Encouraging increased intake of high protein foods is generally recommended for individuals with Parkinson's disease, but it is not directly related to the acute onset of confusion.
D. Checking the mother's temperature is a direct action to assess for infection, which can be a cause of acute confusion, especially in older adults.
E. Pain with urination could indicate a urinary tract infection, which is another common cause of confusion in the elderly. It is important to assess for this possibility.
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