A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful.
I can't take it anymore.”. Which of the following responses should the nurse make first?
"Tell me what makes you feel stressed.”.
"How have you dealt with stress in the past?".
"Let's talk more about what you are experiencing.”.
"Are you thinking of harming yourself?". .
The Correct Answer is D
Choice A rationale:
Asking the client to describe what makes them feel stressed is important for understanding their situation, but it is not the immediate priority when there is concern about self-harm.
Choice B rationale:
Inquiring about the client's past coping mechanisms is relevant, but it should not be the first question when there is a potential risk of self-harm.
Choice C rationale:
Discussing what the client is experiencing is important, but it is not the primary concern when there is a risk of self-harm.
Choice D rationale:
Asking the client if they are thinking of harming themselves is the immediate priority in this situation. It helps assess the client's safety and the need for further intervention. Please let me know if you have more questions or need further explanations. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The statement "I don't feel anything but numbness anymore" is indicative of anhedonia, which is a core symptom of clinical depression. Anhedonia is the inability to experience pleasure or interest in previously enjoyed activities. Reporting this statement to the provider is important as it suggests a significant emotional disturbance.
Choice B rationale:
While the statement "It'll be a long time before I'm happy again" does indicate a sense of hopelessness or prolonged sadness, it is not as specific to clinical depression as the presence of anhedonia. Clinical depression involves a range of symptoms, and the absence of pleasure or emotions (anhedonia) is a more concerning sign.
Choice C rationale:
Feeling angry at the world is a common emotional response to grief and loss and is not a direct indication of clinical depression. It is important to consider the context of grief when assessing client statements.
Choice D rationale:
Expressing reliance on family support is a healthy coping mechanism in response to grief and loss. It does not necessarily indicate clinical depression but rather a natural response to seeking support during a difficult time.
Correct Answer is D
Explanation
The correct answer is D. Hyperthermia.
Choice A reason: Hyperglycemia, which is an elevated blood glucose level, is not typically a direct manifestation of alcohol withdrawal. Alcohol withdrawal can sometimes lead to poor oral intake or vomiting, which might indirectly affect blood sugar levels, but hyperglycemia itself is not a primary concern in the context of alcohol withdrawal.
Choice B reason: Decreased blood pressure During alcohol withdrawal, the sympathetic nervous system is often overactive, leading to symptoms such as increased blood pressure, rather than decreased. Therefore, decreased blood pressure is not a common manifestation of alcohol withdrawal. Normal blood pressure ranges for adults are systolic BP of 100-120mmHg and diastolic BP of 70-80mmHg.
Choice C reason: Decreased heart rate Similar to blood pressure, the heart rate typically increases during alcohol withdrawal due to sympathetic nervous system overactivity. A normal resting heart rate for adults ranges from 60 to 100 beats per minute (bpm). Decreased heart rate is not expected during alcohol withdrawal.
Choice D reason: Hyperthermia, or elevated body temperature, is a common symptom of alcohol withdrawal. This occurs as part of the body’s response to the sudden absence of alcohol, and can be a part of the withdrawal syndrome, which includes a range of symptoms from mild anxiety to severe complications like seizures. Normal body temperature ranges from 97°F (36.1°C) to 99°F (37.2°C).
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