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 B
Explanation
Choice A reason:
Feeling angry at the world is a common reaction to grief and loss. Anger is one of the stages of grief and does not necessarily indicate clinical depression. While it is important to monitor the client's emotional state, anger alone is not a definitive sign of depression.
Choice B reason:
Expressing a sense of numbness and an inability to feel emotions is a significant indicator of clinical depression. This symptom, known as anhedonia, reflects a loss of interest or pleasure in most activities and is a core feature of major depressive disorder. It is crucial to report this to the provider for further evaluation and intervention.
Choice C reason:
Acknowledging the importance of family support is a positive coping mechanism. This statement indicates that the client recognizes their support system, which is beneficial for managing grief. It does not suggest clinical depression.
Choice D reason:
Feeling that it will take a long time to be happy again is a normal part of the grieving process. Grief can be prolonged, and it is natural for clients to feel that their happiness is distant. This statement alone does not indicate clinical depression
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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