A behavioral health unit nurse is caring for a newly admitted client.
Complete the following sentence by using the lists of options:
The client demonstrates risk for
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
The client demonstrates risk for feelings of hopelessness due to powerlessness.
Choice A: Inadequate Nutrition
Reason: While the client ate only one bite of toast, which might suggest inadequate nutrition, the primary concern based on the provided information is not related to nutrition. The client’s symptoms and history point more towards emotional and psychological issues rather than nutritional deficiencies.
Choice B: An Unkempt Appearance
Reason: The client is described as wearing wrinkled sweatpants and a stained t-shirt, which indicates an unkempt appearance. However, this is more a symptom of their overall mental state rather than the primary risk factor. The unkempt appearance is a result of their depressive symptoms and feelings of hopelessness.
Choice C: Inappropriate Thought Process
Reason: There is no direct evidence in the provided information that the client is experiencing inappropriate thought processes. The client’s thoughts and feelings, such as sadness and hopelessness, are consistent with depression but do not indicate a disturbed or inappropriate thought process.
Choice D: Feelings of Hopelessness
Reason: The client explicitly states feeling “sad and hopeless.” This is a significant indicator of depression and is a primary concern. Feelings of hopelessness are a major risk factor for worsening depression and potential self-harm.
Choice E: Powerlessness
Reason: The client’s history of losing their parents and subsequent deep depression, along with their current lack of interest in activities and social connections, suggests a sense of powerlessness. This feeling of powerlessness can exacerbate their feelings of hopelessness and depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"},"H":{"answers":"B"}}
Explanation
a. Methadone 40 mg PO daily: This is contraindicated. Methadone is primarily used for opioid withdrawal and maintenance, not for alcohol withdrawal.
b. Nutritional consult: This is anticipated. Nutritional therapy can help balance out the loss of nutrients due to heavy drinking.
c. Perform Alcohol Use Disorders Identification Test (AUDIT): This is contraindicated. AUDIT is a screening tool for assessing alcohol consumption and related problems, but it’s not typically used once a diagnosis of alcohol use disorder has been established and the patient is in withdrawal.
d. Complete blood count and basic metabolic profile: This is anticipated. These tests can help assess the patient’s overall health status and identify any potential complications related to alcohol withdrawal67.
e. Group therapy: This is anticipated. Group therapy can provide peer support and is often beneficial in the treatment of alcohol use disorder.
f. Schedule electroconvulsive therapy (ECT): This is contraindicated. ECT is typically used for severe depression and other psychiatric disorders, not for alcohol withdrawal.
g. Diazepam 10 mg PO three times a day: This is anticipated. Diazepam, a benzodiazepine, is commonly used in the management of alcohol withdrawal to reduce symptoms and prevent complications.
h. Propranolol 40 mg PO twice a day: This is contraindicated. Propranolol, a beta-blocker, is not typically used as a first-line treatment for alcohol withdrawal. It may be used to manage some symptoms such as tremors or high blood pressure, but it does not prevent seizures, a potential complication of alcohol withdrawal.
Correct Answer is D
Explanation
Choice A reason:
A client lying about suicidal ideation to their provider does not fall under mandatory reporting unless there is evidence or suspicion of harm to self or others. In this case, the client has reported lying, which indicates there is no actual suicidal ideation or intent.
Choice B reason:
While smoking marijuana may be illegal in some jurisdictions, it does not typically require mandatory reporting by a nurse unless it directly affects patient care or involves minors.
Choice C reason:
Theft from an employer is a legal issue but does not require mandatory reporting by a nurse unless it involves stealing medication or other actions that could harm patients.
Choice D reason:
This choice clearly involves child abuse, which is a reportable offense. Nurses are mandated reporters for any suspected child abuse or neglect. Tying a child to a bed as punishment can cause physical and emotional harm, and it is the nurse's duty to report this to the appropriate agency to ensure the child's safety.
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