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 D
Explanation
A. Securing the chest tube to the stretcher is important, but not the most critical action as it does not directly affect the function of the chest tube during transport.
B. Administering pain medication is important for comfort but is not the most immediate concern during urgent transport for a CT scan.
C. Marking the amount of chest drainage is a routine monitoring action and can be done before or after transport, thus not the most critical action.
D. Keeping the chest tube container below the site of insertion is crucial to maintain proper
drainage by gravity and prevent complications such as tension pneumothorax, which can be life- threatening.
Correct Answer is ["B","H"]
Explanation
A. Chesty: Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.
B. Start oxygen 3 L via nasal cannulA Increased oxygen flow is necessary to manage the
client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C. Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D. Normal saline 150 ml/hour: Helps maintain hydration but is secondary to respiratory support in this scenario.
E. NPO: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F. Start an IV: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G. Sputum culture: Useful for diagnosing the cause of respiratory symptoms but not a first- line action.
H. Place the client on a cardiorespiratory monitor: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.
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