A client is admitted with abdominal pain, loss of appetite, and a weight loss of 25 lb (11 kg) in the last four months. During the admission assessment, the client describes to the nurse of having no interest in playing cards with friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

"Risk for self-directed violence as evidenced by feelings of hopelessness."

"Chronic low self-esteem as evidenced by feelings of worthlessness."

"Anxiety as evidenced by abdominal discomfort secondary to depression."

"Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months."

Answer and Explanation

The Correct Answer is A

A. "Risk for self-directed violence as evidenced by feelings of hopelessness": The client’s feelings of hopelessness, combined with significant weight loss and loss of interest in activities, suggest possible depression. Hopelessness is a key symptom of depression, which can increase the risk for self-harm or suicide.

B. "Chronic low self-esteem as evidenced by feelings of worthlessness": Feelings of worthlessness are part of the larger picture of the client’s depression. The priority is to address the immediate risk of harm, which takes precedence over chronic low self-esteem.

C. "Anxiety as evidenced by abdominal discomfort secondary to depression": While abdominal discomfort can be a symptom of depression, it is secondary to the more immediate concern of the client’s potential risk for self-directed violence.

D. "Imbalanced nutrition as evidenced by 25 lb (11 kg) weight loss in four months": The significant weight loss is concerning, but it is likely a result of the client’s depression. The focus should first be on addressing the client’s safety, followed by nutrition and weight restoration.

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Correct Answer is A

Explanation

A. Chest tube insertion tray: Thoracentesis may lead to complications like pneumothorax, especially in clients with lung disease such as emphysema. If air or fluid reaccumulates or lung collapse occurs, a chest tube may be urgently required to re-expand the lung and drain air or fluid buildup.

B. Intubation tray: While intubation may be needed in cases of severe respiratory failure, it is not the first-line equipment after an ineffective thoracentesis. It would only be used if the patient is unable to breathe adequately despite other interventions.

C. Ventilator: Mechanical ventilation is not immediately needed for a failed thoracentesis unless the client develops respiratory failure. It is a secondary measure if oxygenation cannot be maintained with basic support.

D. Crash cart: A crash cart is essential during cardiac arrest or life-threatening emergencies. It is not the most appropriate equipment to have specifically for an ineffective thoracentesis unless severe complications arise suddenly.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}

Explanation

Rationale for Correct Choices:

Anemia: The lab values indicate that the client’s hemoglobin and hematocrit are lower than normal, suggesting anemia. Anemia in this case is likely due to blood loss from the trauma, as the client has internal hemorrhaging, with blood noted in the peritoneum.
Blood loss: The client’s abdominal trauma, with liver and spleen lacerations and blood in the peritoneum, is a clear indicator of significant internal bleeding. This blood loss is directly responsible for the anemia seen in the lab results.
Hemodilution from intravenous fluids: The client is receiving IV fluids at a rate of 100 mL/hr, which can dilute the blood and artificially lower hematocrit and hemoglobin levels. This is a common effect when fluids are given in large amounts, as the fluid increases plasma volume without immediately increasing red blood cells.

Rationale for Incorrect Choices:

Acidosis: Acidosis typically presents with changes in blood pH and respiratory or renal compensation, which is not indicated by the client's lab results or current status. There are no signs of metabolic or respiratory acidosis in the current clinical picture.
Rh factor sensitization: Rh factor sensitization usually occurs during pregnancy when Rh-negative mothers develop antibodies against Rh-positive fetal blood cells. This is unrelated to the client’s trauma and lab findings, which focus on anemia.
Hypovolemia: Hypovolemia is more directly related to the blood loss and the hemodilution effect from intravenous fluid administration, making it a contributing but less specific factor in the anemia diagnosis.
Disseminated intravascular coagulation (DIC): DIC is characterized by widespread clotting followed by bleeding. There is no evidence of abnormal clotting or bleeding issues in the lab results or clinical presentation, such as abnormal coagulation studies.
Pregnancy: Pregnancy is not applicable in this case as the client's history does not mention any signs or symptoms of pregnancy. Anemia in this patient is related to trauma-induced blood loss and subsequent hemodilution, not pregnancy-related causes.
Clotting cascade: While it is relevant to conditions like DIC or bleeding disorders, it does not directly explain the client's low hemoglobin or hematocrit. The lab results are more consistent with blood loss and fluid resuscitation.
Blood administration: There is no mention of the client receiving blood products. While blood transfusion might be needed given the blood loss, there is no current indication from the lab results that blood administration has occurred or is required at this point.
Immune response: An immune response is typically seen in infections or allergic reactions. The client’s current clinical condition and lab results do not suggest an infection or immune response but rather trauma-related blood loss and fluid effects.
Hypoventilation: Hypoventilation typically leads to respiratory acidosis or elevated CO2 levels, but the client is intubated and on mechanical ventilation, with no indication of respiratory distress or acidosis.
Hypoxia: Although trauma patients may experience hypoxia, the client’s oxygen saturation is 100%, and there is no indication of respiratory distress or hypoxia in the lab results. The anemia is more related to blood loss rather than a lack of oxygen in the tissues.

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Naxlex Comprehensive Predictor Exams

The nurse is assisting the healthcare provider with a thoracentesis for a client who has emphysema. Which equipment should the nurse have at the bedside in the event the procedure is ineffective?

Correct Answer is A

Explanation

Exhibits Drag from Word Choices to complete the sentence. According to the lab values, the client has dropdownrelated to dropdownordropdown.

Correct Answer is {"dropdown-group-1":"E","dropdown-group-2":"E","dropdown-group-3":"D"}

Explanation

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