The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
Explore changes in life that have occurred after the loss.
Suggest the need for a psychiatric consultation.
Offer a referral to pastoral counseling.
Encourage attending a local support group.
The Correct Answer is A
Choice A rationale:
Exploring changes in life that have occurred after the loss is the first action the nurse should take. This allows the nurse to assess the client's grief, identify specific stressors, and understand how the loss is impacting the client's daily life and emotional well-being. It provides valuable information for tailoring further interventions and support.
Choice B rationale:
Suggesting the need for a psychiatric consultation may be premature as the nurse should first assess the client's grief and coping mechanisms. Referral for psychiatric consultation should be considered if the client's emotional distress is severe, persistent, or significantly impacting their functioning.
Choice C rationale:
Offering a referral to pastoral counseling may be appropriate for some clients, but it should not be the first action. The nurse should assess the client's needs and preferences before making such a referral.
Choice D rationale:
Encouraging attendance at a local support group can be beneficial, but it should not be the initial step. The nurse should first assess the client's current emotional state and needs to determine the most appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B"}
Explanation
Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.
Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.
Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis
Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.
Correct Answer is B
Explanation
Choice A rationale:
Cocaine is a stimulant and typically leads to increased heart rate (tachycardia) and respiratory rate (tachypnea). Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) would be atypical findings with cocaine use.
Choice B rationale:
Cocaine is a stimulant drug that typically produces effects such as increased heart rate, increased blood pressure, stimulation, euphoria, and dilated pupils. These physiological and psychological effects are common when someone has used cocaine.
Choice C rationale:
While cocaine use can cause hallucinations and paranoia during intoxication or withdrawal, these symptoms are not typically the primary manifestations. The most common initial effects are stimulation and increased alertness.
Hallucinations and delusions may occur with substance use, but they are not the most expected or specific findings for cocaine use.
Choice D rationale:
Cocaine use is associated with increased energy, euphoria, and heightened arousal. Lethargy and depression are more likely during the comedown phase or withdrawal from cocaine, rather than immediately after use.
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