A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?
Identify support groups in the community for long-term treatment.
Assist the client to identify negative effects of chemical dependency.
Determine the presence and degree of suicidal risk.
Refer client to mental health care provider for evaluation and treatment.
The Correct Answer is C
The nurse should determine the presence and degree of suicidal risk when caring for a client who has a depressive disorder, is in alcohol withdrawal, and reports a recent job loss. This intervention is the priority because the client is at increased risk of suicidal ideation or behavior due to the combination of depression, alcohol withdrawal, and recent job loss. Identifying support groups in the community for long-term treatment.
choice A and referring the client to a mental health care provider for evaluation and treatment.
choice D are important interventions but are not the priority at this time. Assisting the client to identify the negative effects of chemical dependency.
choice B may be necessary but does not address the priority concern of suicidal risk.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is C
Explanation
"Be direct and honest when communicating with the client." Being direct and honest with the client about the situation is essential to build trust and promote open communication. Protecting client confidentiality and privacy is crucial for client safety and well-being. If the client feels comfortable in a safe and non-threatening environment, then they are more likely to open up and discuss their situation. Displaying disapproval or probing the client can make the situation worse and result in the client withdrawing further. Inviting a family member to be present during the nursing history is not appropriate given the sensitive and personal nature of the discussion.
Option A: "Display disapproval toward the perpetrator" - Not appropriate for the clinical setting
Option B: "Probe the client to offer a factual account of the abuse" May make the client withdraw more, not appropriate for the clinical setting
Option D: "Invite a family member to be present for the nursing history" - Not appropriate for the sensitive nature of the discussion Each of the other options is not appropriate given the sensitive nature of the conversation.
Correct Answer is C
Explanation
Constipation. Constipation is a common symptom of anorexia nervosa, as it can result from severe food restriction, dehydration, electrolyte imbalance, or laxative abuse. People with anorexia may also experience abdominal pain and bloating due to constipation.
Choice A. Hyperkalemia. Hyperkalemia is a condition of high potassium levels in the blood. It is not a typical symptom of anorexia, as people with anorexia tend to have low potassium levels due to vomiting, diuretic use, or inadequate intake.
Hyperkalemia can cause irregular heart rhythms, muscle weakness, and paralysis.
Choice B. Tachycardia. Tachycardia is a condition of fast heart rate. It is not a common symptom of anorexia, as people with anorexia tend to have bradycardia, which is a slow heart rate. Bradycardia can result from starvation, dehydration, or electrolyte imbalance and can lead to cardiac arrest. Tachycardia can occur in some cases of anorexia due to dehydration, anxiety or refeeding syndrome.
Choice D. Metrorrhagia. Metrorrhagia is a condition of irregular or excessive bleeding between menstrual periods. It is not a usual symptom of anorexia, as people with anorexia tend to have amenorrhea, which is the absence of
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