A nurse is caring for a client:

The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

Click to highlight the areas that the nurse should react to immediately. The client has returned to work at an accounting firm and has started going to a grief support group. She reports she is seeking care from a healthcare professional because her father is worried about her. The client says she only gets 2 to 3 hours of sleep due to nightmares about the crash. She informs that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy" after the accident, especially when she is in the car. She also stated, "I feel so sad that I can't seem to feel anything at all" In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2 to 3 hours of sleep

She feels that she is "jumpy" after the accident

I feel so sad that I can't seem to feel anything at all"

The client has returned to work at an accounting firm

Answer and Explanation

The Correct Answer is ["A","B","C"]

In the scenario presented, the nurse should prioritize addressing the client's sleep disturbances, heightened startle response, and feelings of sadness and numbness. These symptoms may indicate acute stress reaction or post-traumatic stress disorder, conditions that can occur after experiencing a traumatic event such as a car crash. Immediate interventions could include providing a safe and calm environment, offering support and reassurance, assessing for risk of harm to self or others, and referring to mental health professionals for further evaluation and treatment. It's also important to acknowledge the client's proactive steps, such as joining a grief support group and exercising, which are positive coping strategies. The nurse should collaborate with the client to build on these healthy habits while addressing the more distressing symptoms with appropriate care and referrals.

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Correct Answer is C

Explanation

A. While reinforcing the need for group therapy sessions is important, it does not address the immediate safety concerns associated with violent behavior. Therapy is a long-term solution, but immediate action is necessary to prevent harm.
B. Telling the mother to describe her feelings of helplessness to the adolescent is not appropriate. It may increase the adolescent's frustration or aggression, rather than de-escalating the situation.
C. Advising the mother to call the police if violent behavior occurs again is the most important intervention. Violent actions, such as putting a fist through a window, indicate a risk for harm to self or others, and law enforcement intervention may be needed to ensure safety.
D. Referring the mother for psychiatric evaluation may be helpful if she is experiencing anxiety or depression, but it does not address the immediate concern of the adolescent's violent behavior.

A. Nausea and vomiting. B. Short-term memory loss. C. Five-pound (2.3 kg) weight gain. D. Depressed affect.

Correct Answer is A

Explanation

A. Nausea and vomiting could indicate potential lithium toxicity, which requires immediate medical attention to prevent serious complications.
B. Short-term memory loss is a known side effect of lithium therapy but may not require immediate medical attention unless severe or persistent.
C. Weight gain is a common side effect of lithium, but a five-pound (2.3 kg) gain may not be considered significant enough to warrant immediate medical attention unless it occurs rapidly or is accompanied by other symptoms.
D. Depressed affect is a symptom of depression and may be related to the client's underlying condition but may not require immediate medical attention unless it poses a risk to the client's safety.

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?

Correct Answer is A

Explanation

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