A female client is admitted with complaints of abdominal pain, loss of appetite, and a weight loss of 25 pounds (11 kg) in the last four months. During the admission assessment, the client tells the nurse that she has no interest in playing cards with her friends anymore and feels worthless most days. Which nursing problem should the nurse address first?

Anxiety as evidenced by abdominal complaints secondary to depression.

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

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

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

Answer and Explanation

The Correct Answer is D

The client's statement of feeling worthless most days and having no interest in activities she previously enjoyed indicates a potential risk for self-directed violence, including self-harm or suicidal ideation. These signs are significant and require immediate attention and intervention by the nurse.

Assessing and addressing the client's risk for self-directed violence is of utmost importance to ensure her safety and well-being. The nurse should initiate a thorough assessment of the client's mental health, including assessing for any suicidal ideation, intent, or plans. It is crucial to establish a supportive and non-judgmental environment for the client to express her feelings and concerns.

The nurse should collaborate with the healthcare team to develop an appropriate care plan that may involve interventions such as close observation, involving a mental health professional, implementing safety measures, and providing emotional support.

While addressing other nursing problems, such as anxiety, imbalanced nutrition, and chronic low self-esteem, is important, the immediate concern is the client's risk for self-directed violence due to her feelings of hopelessness.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["1.4"]

Explanation

Calculate the total dosage required: 44 mcg/kg * 65 kg = 2860 mcg. Convert mcg to mg: 2860 mcg ÷ 1000 = 2.86 mg.

Divide by concentration: 2.86 mg ÷ 2 mg/mL = 1.43 mL.

Considering the vial contains 2 mg/mL, the nurse should administer around 1.43 mL, which can be rounded to 1.4 mL.

A. Cerebral edema B. Acute asphyxia C. Hypertension D. Respiratory distress E. Hyperthermia F. Subdural hemorrhage

Correct Answer is ["A","B","D","F"]

Explanation

A) Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B) Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C) Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D) Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E) Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F) Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.4"]

Explanation

Correct Answer is ["A","B","D","F"]

Explanation

The nurse discovers that a male client has attempted suicide by slashing his wrists. Which action(s) should the nurse do first?

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

A client with diabetes insipidus (DI) has an average urinary output of 500 ml. of dilute urine every hour for the last 4 hours. Which laboratory test is most important for the nurse to monitor?

The nurse-manager is involved in agency restructuring. During this re-engineering process, it is most important for the nurse to address which employee concern?

The nurse notices that a male client is particularly delusional one afternoon. He begins to pace the floor and appears to be losing control of himself. Which intervention is best for the nurse to implement?

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?