A nurse is collecting the medical history of a client. The client reports that they have experienced violence in the past with a previous partner. What is an immediate concern of the nurse?
The client reports that they have no social support system, but has an appointment with a case worker in two weeks.
The client reports that they are experiencing frequent gastrointestinal issues.
The client reports that they are currently living in a safe place.
The client reports that they are currently going to counseling.
The Correct Answer is A
A. The client reports that they have no social support system, but has an appointment with a caseworker in two weeks. Lack of a social support system poses a risk for isolation, depression, and potential difficulty accessing resources. Immediate intervention may be required to provide emotional and practical support.
B. The client reports that they are experiencing frequent gastrointestinal issues: While important, these may be psychosomatic and can be addressed after ensuring the client’s emotional and physical safety.
C. The client reports that they are currently living in a safe place: Being in a safe environment is reassuring and not an immediate concern.
D. The client reports that they are currently going to counseling: Ongoing counseling is a positive step toward healing and does not require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "This medication can cause a dry cough.": A dry cough is not a common side effect of sertraline.
B. "I should call the provider if I experience excessive sweating and muscle twitching." Excessive sweating and muscle twitching could indicate serotonin syndrome, a potentially life-threatening condition associated with SSRIs like sertraline. Early recognition and prompt intervention are crucial.
C. "This medication can cause harmless, temporary changes to my ability to taste and smell.":
Changes in taste or smell are not typical side effects of sertraline. This statement is incorrect and does not reflect the drug's known side effect profile.
D. "I need to decrease my sodium intake while on this medication.": Sodium intake is not typically affected by sertraline use. However, sertraline can cause hyponatremia in some cases, especially in older adults.
Correct Answer is B
Explanation
A. Reinforce reality with the client. While reinforcing reality can help in addressing the client's hallucinations (seeing bugs), it may not be the immediate priority when the client is experiencing severe panic.
B. Instruct the client to take deep breaths: Helping the client to take deep breaths can provide immediate relief from acute anxiety by promoting relaxation and helping to reduce the physiological symptoms of panic. Once the client is calmer, other interventions can be considered.
C. Assist the client to identify the cause of the anxiety: Insight into triggers is more appropriate after the acute episode resolves.
D. Administer an antianxiety medication to the client: While this may be necessary, it is not the immediate first action in this scenario.
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