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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Glucose and calcium levels: During thyrotoxic crisis, the body’s metabolism is increased, which can lead to hyperglycemia. Additionally, calcium levels may fluctuate due to the impact of thyroid hormones on bone metabolism, making these values critical to monitor.
B. Electrolytes and hemoglobin: While monitoring electrolytes is important, they are not the most critical values in a thyrotoxic crisis. Hemoglobin levels are not directly impacted by thyroid storm and are less likely to provide essential insights for managing this condition.
C. Renal and liver function tests: While important for general health monitoring, renal and liver function tests are not the most critical in the immediate management of a thyrotoxic crisis. The focus should be on metabolic and electrolyte imbalances rather than organ function tests.
D. Blood and urine cultures: Blood and urine cultures are used to detect infections, they are not a priority during a thyrotoxic crisis unless there is a concern about infection. The primary focus should be on managing thyroid hormone levels and associated metabolic effects.
Correct Answer is ["5.6"]
Explanation
Rationale:
- Convert the client's weight from pounds (lb) to kilograms (kg).
Weight in kg = 132 lb / 2.2 lb/kg
= 60 kg.
- Calculate the desired dose per minute in micrograms (mcg).
Desired dose per minute (mcg/min) = Desired dose (mcg/kg/min) × Weight (kg)
= 5 mcg/kg/min × 60 kg
= 300 mcg/min.
- Convert the desired dose from micrograms per minute (mcg/min) to milligrams per hour (mg/hr).
1 mg = 1000 mcg
1 hr = 60 min
Desired dose in mg/hr = (300 mcg/min / 1000 mcg/mg) × 60 min/hr
= 0.3 mg/min × 60 min/hr
= 18 mg/hr.
- Determine the concentration of the available Dopamine solution in milligrams per milliliter (mg/mL).
Available concentration = Total medication (mg) / Total volume (mL)
= 1600 mg / 500 mL
= 3.2 mg/mL.
- Calculate the IV pump rate in milliliters per hour (mL/hr).
IV pump rate (mL/hr) = Desired dose (mg/hr) / Available concentration (mg/mL)
= 18 mg/hr / 3.2 mg/mL
= 5.625 mL/hr.
- Round the answer to the nearest tenth.
= 5.6
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.