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. Placing an indwelling urinary catheter and measuring strict intake and output may be necessary for comprehensive assessment and management but is not the priority action in this situation, which suggests a possible stroke.
B. Keeping the bed in the lowest position and initiating seizure and fall precautions are important for safety, but the client's symptoms are suggestive of a stroke, and immediate evaluation and potential treatment are needed.
C. Starting two large-bore IV catheters and reviewing inclusion criteria for IV fibrinolytic therapy is the priority action. The client's symptoms, including right-sided weakness and sluggish speech, suggest a potential ischemic stroke. IV fibrinolytic therapy (e.g., tissue plasminogen activator) is time-sensitive and may be indicated for eligible patients with acute ischemic stroke.
D. Maintaining elevated positioning of the dependent joints on the affected side is not the priority action in this situation. Immediate assessment and potential treatment for a suspected stroke are needed.
Correct Answer is ["A","B","E","F","G"]
Explanation
O2 saturation: Directly reflects the level of oxygen in the blood.
Respiratory rate 28 bpm: Indicates increased effort to obtain oxygen.
Anxious, Restless: Neurological signs of inadequate oxygenation.
BP 145/89 mmHg: Elevated blood pressure can be a response to hypoxia.
Heart Rate 101 bpm: Increased heart rate is a compensatory mechanism for hypoxia.
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