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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["B","D","E"]

Explanation

A. While managing pain is important, the client did not report significant pain, making it a lower priority in this scenario.
B. Quitting smoking is crucial for the client's respiratory health, especially given the history of smoking and current respiratory symptoms.
C. There is no indication that the client is at risk of skin breakdown; thus, it is not a priority in the immediate discharge plan.
D. Maintaining an oxygen saturation of 96% without supplemental oxygen is a direct indicator of improved respiratory function and a key goal for discharge.
E. Being afebrile for 24 hours would indicate that the infection is under control, which is a primary concern for discharge after presenting with flu-like symptoms.

A. Remind the UAP to apply a fitted respirator mask before entering the client's room. B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status. C. Review the need for the UAP to wear a face mask while in close contact with the client. D. Assign the UAP to provide care for another client and assume full care of the client.

Correct Answer is C

Explanation

A. Remind the UAP to apply a fitted respirator mask before entering the client's room: While respiratory protection is important when caring for a client with influenza, the situation described does not warrant the use of a fitted respirator mask for the UAP. Standard precautions, including wearing a face mask, gloves, and gown, are typically sufficient for influenza.
B. Instruct the UAP to notify the nurse of any changes in the client's respiratory status: This instruction is important for overall client monitoring but does not directly address the issue of appropriate personal protective equipment (PPE for the UAP.

C. Review the need for the UAP to wear a face mask while in close contact with the client: Correct! The nurse should remind the UAP of the importance of wearing a face mask when providing care to a client with influenza. Face masks help prevent the spread of respiratory droplets and protect both the client and healthcare workers from infection.
D. Assign the UAP to provide care for another client and assume full care of the client: While reassigning the UAP is an option if they are not following proper infection control procedures, it's important to address the issue directly by reminding them of the need for appropriate PPE.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E"]

Explanation

A client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive person (UAP) donning gloves and a gown to assist the client. Which action should the nurse take?

Correct Answer is C

Explanation

The nurse receives shift report about a male client with obsessive-compulsive disorder. The nurse completes moming rounds and approaches the cent while he is repeatedly washing the top of the same table. Which intervention should the nurse implement?

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A client is unable to void following a procedure, so the nurse obtains a prescription to perform a straight catheterization. After inserting the catheter, the nurse observes that the client has an immediate output of 500 mL of clear yellow urine. Which action should the nurse implement next?

The client with influenza needs help in transferring to the bedside commode. The nurse observes the unlicensed assistive personnel (UAP) don gloves and a gown to assist the client. Which action should the nurse take?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?

A male client reports to the on-call clinic nurse that he took tadalafil 10 mg by mouth two hours ago and his skin now feels flushed. He reports a history of stable angina but denies experiencing any current or recent chest pain. Which action should the nurse take?