A nurse is collecting data from a new client.
Which of the following Questions should the nurse include when determining the client's psychosocial status?
"Who do you talk to when you are upset?"
"Do you have medical insurance?"
"When did you last have a mammogram?"
"How old were you when you started your menses?"
The Correct Answer is A
Choice A rationale
"Who do you talk to when you are upset?" explores the client's social support system, which is a critical component of their psychosocial status. Social support can buffer stress, provide emotional comfort, and contribute to overall well-being. Understanding who the client relies on for support helps assess their coping mechanisms and social connectedness.
Choice B rationale
"Do you have medical insurance?" pertains to the client's access to healthcare resources and socioeconomic status. While these factors can influence overall well-being, they are not direct indicators of the client's psychosocial status, which focuses more on their mental, emotional, and social functioning.
Choice C rationale
"When did you last have a mammogram?" is a question related to the client's physical health and preventive care practices, specifically relevant for female clients. It does not directly assess their psychosocial status, which encompasses their emotional state, social interactions, and coping abilities.
Choice D rationale
"How old were you when you started your menses?" is a question about the client's sexual and reproductive health history, relevant for female clients. While significant life events can indirectly impact psychosocial well-being, this specific question does not directly assess their current emotional state, social relationships, or coping mechanisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale: Blood glucose level
A blood glucose level of 200 mg/dL is elevated, suggesting possible hyperglycemia. Clozapine, an atypical antipsychotic, can cause metabolic effects, including insulin resistance, leading to diabetes. This warrants further evaluation by the provider to determine if glucose monitoring or treatment adjustments are needed.
Choice B rationale: WBC count
A WBC count of 4,800/mm³ is low, which is concerning because clozapine can cause agranulocytosis, a severe condition where white blood cells drop significantly, increasing the risk of infection. Since the client is on clozapine, the provider must be informed to assess the need for additional lab monitoring or medication adjustments.
Choice C rationale: Temperature
A temperature of 37.8°C (100.0°F) may indicate a mild fever, which is concerning in the context of a low WBC count. Since clozapine increases infection risk due to potential agranulocytosis, this temperature should be reported to rule out an underlying infection.
Choice D rationale: Blood pressure
A blood pressure of 110/68 mm Hg is within the normal range and does not warrant immediate intervention. It is not concerning in this case.
Correct Answer is A
Explanation
Choice A rationale
Implementing 24-hr one-to-one nursing observation is a necessary precaution for a newly admitted adolescent who overdosed on prescription pain medication. This close monitoring allows for continuous assessment of the client's physical and mental status, early detection of any complications, and prevention of further self-harm attempts, especially given the prescriptions for an anxiolytic and an SSRI, which could have delayed or paradoxical effects in an overdose situation.
Choice B rationale
Restricting interactions with other clients might increase the adolescent's feelings of isolation and depression, which could be counterproductive to their mental health recovery. Therapeutic interactions with peers can be beneficial.
Choice C rationale
Documenting the client's behavior every 2 hr is a standard nursing practice, but it is not sufficient for a client at high risk for self-harm following an overdose. Continuous observation provides immediate intervention capability.
Choice D rationale
Administering prescribed medication via the IM route is not necessarily a standard precaution for an overdose. The route of administration depends on the specific medication and the client's condition. Oral administration is usually preferred when the client is stable and can tolerate it.
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