A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
Refer the client to a mental health care provider for evaluation and treatment.
Determine the presence and degree of suicidal risk.
Identify support groups in the community for long-term treatment.
Assist the client to identify negative effects of chemical dependency.
The Correct Answer is B
Choice A reason:
Referring the client to a mental health care provider is an important step, but it may not be the immediate priority. The referral process can be initiated once the client's immediate safety and acute needs are addressed.
Choice B reason:
Determining the presence and degree of suicidal risk is the priority nursing intervention. Clients with depressive disorders, especially those experiencing significant life stressors such as job loss and undergoing alcohol withdrawal, are at a higher risk for suicide. It is crucial to assess their risk and take appropriate measures to ensure their safety.
Choice C reason:
Identifying support groups is a valuable part of long-term treatment and recovery, but it is not the immediate priority. Support groups can provide ongoing assistance and a sense of community once the client is stable and ready to engage in long-term recovery.
Choice D reason:
Assisting the client to identify the negative effects of chemical dependency is an important aspect of treatment, but it is not the immediate priority. This intervention is part of the client's long-term recovery and education process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.
Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.
Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.
Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.
Correct Answer is ["B","D","E"]
Explanation
Choice A reason:
Regular exercise is generally not considered a predisposing factor for the development of anxiety disorders. In fact, regular physical activity is often recommended as a part of the treatment plan for anxiety because it can help reduce symptoms. Exercise can improve mental health by reducing levels of the body's stress hormones, such as adrenaline and cortisol. It also stimulates the production of endorphins, chemicals in the brain that are the body's natural painkillers and mood elevators.
Choice B reason:
A family history of anxiety disorders can be a predisposing factor. Anxiety disorders can run in families, suggesting that a combination of genes and environmental stresses can produce the disorders. If a close family member has an anxiety disorder, it may increase the likelihood that an individual will develop one as well.
Choice C reason:
Regular meditation practice is typically not a predisposing factor for anxiety disorders; rather, it is often used as a coping mechanism to manage anxiety. Meditation can help reduce stress levels and improve emotional health, which may decrease the risk of developing an anxiety disorder.
Choice D reason:
Being a perfectionist can sometimes be a predisposing factor for anxiety disorders. Perfectionism is often associated with fear of failure, fear of making mistakes, and a tendency to experience high levels of stress and pressure, which can contribute to the development of anxiety disorders.
Choice E reason:
Excessive caffeine consumption can be a predisposing factor for anxiety disorders. Caffeine is a stimulant that can mimic the symptoms of anxiety, such as increased heart rate and nervousness. People who consume large amounts of caffeine may have an increased risk of developing anxiety disorders.
Choice F reason:
Chronic physical illness can be a predisposing factor for anxiety disorders. Living with a chronic illness can cause significant stress and may lead to the development of anxiety disorders. The constant worry about health, treatments, and the future can be overwhelming and may trigger or worsen anxiety symptoms.
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