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 ["C","D","E","F","I"]
Explanation
Choice A: Impaired cognition can occur during alcohol withdrawal but is not typically an immediate concern requiring urgent intervention. It is more of a general symptom that can be monitored over time.
Choice B: Insomnia is a common symptom of alcohol withdrawal but does not usually require immediate follow-up. It can be managed with supportive care and medications if necessary.
Choice C: Seizures are a severe and potentially life-threatening complication of alcohol withdrawal. They require immediate medical attention to prevent further complications and ensure the client’s safety.
Choice D: Increased blood pressure is a sign of autonomic hyperactivity during alcohol withdrawal. It can indicate severe withdrawal and requires immediate follow-up to prevent complications such as hypertensive crises.
Choice E: An increased heart rate is another sign of autonomic hyperactivity and can indicate severe withdrawal. Immediate follow-up is necessary to manage the client’s cardiovascular status and prevent complications.
Choice F: Diaphoresis (excessive sweating) is a common symptom of severe alcohol withdrawal and indicates autonomic hyperactivity. It requires immediate follow-up to manage the client’s condition.
Choice G: Lack of appetite is a common symptom of alcohol withdrawal but does not typically require immediate follow-up. It can be managed with supportive care and nutritional support1.
Choice H: Vomiting can lead to dehydration and electrolyte imbalances, which are serious concerns during alcohol withdrawal. Immediate follow-up is necessary to manage these risks3.
Choice I: Tremulousness (tremors) is a common and early sign of alcohol withdrawal. It indicates autonomic hyperactivity and requires immediate follow-up to prevent progression to more severe symptoms.
Choice J: Malaise is a general feeling of discomfort and is common during alcohol withdrawal. It does not typically require immediate follow-up but should be monitored as part of the overall care plan.
Correct Answer is B
Explanation
Choice A reason:
Reinforcing teaching about coping mechanisms is a task that requires clinical judgment and the application of nursing knowledge, which are responsibilities that cannot be delegated to assistive personnel. Nurses are responsible for the initial teaching and ongoing reinforcement of coping mechanisms, as they have the training to assess the client's understanding and provide appropriate education.
Choice B reason:
Sitting with a client during mealtimes does not require clinical judgment or specialized nursing knowledge and can be delegated to assistive personnel. This task involves providing support and encouragement to the client, as well as monitoring the client's intake, which are within the scope of duties that assistive personnel can perform.
Choice C reason:
Discussing relapse prevention with the family of a client who has schizophrenia involves therapeutic communication and education that must be based on nursing assessment and planning. This task requires the nurse's expertise in mental health and cannot be delegated to assistive personnel.
Choice D reason:
Administering a rectal suppository is a medication administration task that involves nursing judgment related to assessing the client's condition and understanding the medication's effects. This task cannot be delegated to assistive personnel, as they are not licensed to administer medications.
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