Share This Link

B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.

C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.

D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.

B- Muscle aches and chills: Muscle aches and chills are not typical manifestations of alcohol withdrawal. These symptoms are more commonly associated with opioid withdrawal rather than alcohol withdrawal.

C- Fatigue and depression: Fatigue and depression are common symptoms during alcohol withdrawal. The client may feel tired, lack energy, and experience a low mood due to the neurochemical imbalances that occur during withdrawal.

D- Arrhythmia and respiratory depression: While alcohol withdrawal can lead to some cardiovascular and respiratory symptoms, such as increased heart rate and blood pressure, severe arrhythmia, and respiratory depression are not typical findings. These more severe symptoms may indicate a more severe withdrawal syndrome or coexisting medical conditions that require immediate medical attention.

 Clients experiencing moderate anxiety may speak rapidly as their thoughts race, and they may feel an urgent need to express their concerns. 

C- Chills: Chills are not typically associated with moderate anxiety disorder. Chills are more commonly seen in conditions such as infections or fever.

D- Distorted perceptual field: Distorted perceptual field, also known as perceptual disturbances, is not typically associated with moderate anxiety disorder. Perceptual disturbances refer to sensory experiences such as hallucinations or illusions, which are more commonly seen in severe mental health conditions like psychosis or substance-induced disorders.

A- Reinforce postpartum and newborn care discharge teaching: While reinforcing postpartum and newborn care discharge teaching is an important aspect of care, it is not the priority in this situation. The client's symptoms of feeling "down," sadness, lack of energy, and wanting to cry suggest the possibility of postpartum depression. The nurse should prioritize addressing the client's emotional well-being and assessing for potential risks, rather than focusing on routine postpartum and newborn care teaching.

B- Anticipate a prescription by the provider for an antidepressant: While medication may be part of the treatment plan for postpartum depression, it is not the priority action at this stage. The nurse should first assess the client's condition, including the severity of her symptoms and any potential risk of harm to herself or her newborn. Initiating a discussion about medication can come later, in collaboration with the healthcare provider and based on a comprehensive assessment.

C- Assist the family to identify prior use of positive coping skills in family crises: While supporting the client's family and identifying positive coping skills are important, they are not the priority in this scenario. The immediate concern is addressing the client's symptoms and assessing for potential risks associated with postpartum depression. Once the client's immediate safety and emotional needs are addressed, the nurse can involve the family in the care plan and help them identify and utilize positive coping strategies.

A- Hypotension: Hypotension, or low blood pressure, is not typically associated with chronic stress. In fact, chronic stress often leads to increased sympathetic nervous system activity, which can result in elevated blood pressure.

Increased cognitive awareness: Chronic stress affects cognitive function. You might find it challenging to concentrate, make decisions, or stay mentally sharp.

D- Increased energy: Chronic stress typically leads to a state of exhaustion and fatigue rather than increased energy. Prolonged stress can drain a person's physical and mental energy, resulting in feelings of fatigue, lethargy, and a lack of motivation.

A- "You have given signed consent for the treatments after they were explained to you." - This response does not acknowledge the client's right to refuse the treatment. Even if the client previously provided consent, they still have the right to change their mind and refuse the treatment. Informed consent is an ongoing process, and the client's autonomy should be respected throughout their care.

B- "You can refuse them, but the provider believes they are necessary." - While it may be true that the healthcare provider believes ECT is necessary, this response does not fully acknowledge the client's autonomy. It is important to emphasize the client's right to make decisions about their own healthcare, independent of the provider's opinion. The decision to refuse or accept the treatment should ultimately be made by the client.

C- "You will feel better after the course of treatments." - This response does not address the client's concerns or their right to refuse the treatment. It is essential to respect the client's autonomy and their ability to make decisions about their own care, even if their decision may not align with the potential benefits of the treatment. The nurse should focus on providing information, addressing the client's concerns, and supporting their decision-making process.

B- "Do you receive treatment for any mental health disorders?" helps to assess if there are coexisting mental health issues that may be contributing to or affected by alcohol use.

C- "At what age did you begin drinking alcohol?" helps to understand the timeline of the client's alcohol use and potential early risk factors for developing alcohol use disorder.

D- "Have you received prior treatment for substance use disorder?" provides insights into the client's past attempts at addressing their alcohol use and any prior experiences with treatment.

A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.

B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.

C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.

While choice A, “I haven’t gotten my period yet, and all my friends have theirs,” is a valid concern for a 13-year-old, it is generally a normal part of development. Menarche can occur anywhere between ages 9 and 16, so it’s not uncommon for some girls to start later than their peers. However, it is important to address this concern and provide reassurance. 

B- "My parents treat me like a baby sometimes." This comment suggests a possible issue with parent-child dynamics, but it does not indicate an immediate health concern. The nurse may explore this further during a counseling session or refer the adolescent to a school counselor if necessary.

C- "There's a big pimple on my face, and I worry that everyone will notice it." While acne can impact an adolescent's self-esteem, it is not a priority issue from a health perspective. The nurse can provide support, discuss basic skincare practices, and offer guidance on managing acne if appropriate.

A- Disulfiram is a medication used to support alcohol abstinence by creating unpleasant reactions if alcohol is consumed. It is not typically administered during acute alcohol withdrawal.

B- Naltrexone is used to help individuals with alcohol dependence reduce their alcohol cravings and drinking behavior. It is not typically used during the acute phase of alcohol withdrawal.

D- Acamprosate is a medication used to maintain abstinence from alcohol in individuals who have already stopped drinking. It is not typically used during the acute phase of alcohol withdrawal.