A nurse is evaluating the outcomes for a client who has depression following the death of his wife 3 months ago. Which of the following client statements indicates a need for further intervention?
"I can't help it but I am mad at my wife for leaving me alone."
"I feel better now that I have reestablished a relationship with my son."
"It is hard for me to be around others, but I make a point of going to the community center each week."
"I just don't feel like eating because I never liked to eat alone."
The Correct Answer is A
Choice A reason: Anger towards a deceased spouse can be a sign of unresolved grief and may indicate complicated grief or depression, requiring further intervention.
Choice B reason: Reestablishing relationships is a positive step in coping with loss and suggests progress in managing grief.
Choice C reason: Although it's difficult, the effort to engage with the community is a positive sign of coping and does not typically indicate a need for further intervention.
Choice D reason: A lack of desire to eat due to the absence of a loved one can be a normal part of grieving, but if persistent, it may require intervention to address potential depression.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: While attaching leads for a 12-lead ECG is important, it is not the most immediate action required for a client showing signs of distress and potential hypoxia.
Choice B reason: Obtaining a blood sample is necessary for diagnosing the cause of chest pain but is not the first priority in an emergency situation.
Choice C reason: Initiating oxygen therapy is the first and most critical step in managing a client with severe chest pain, shortness of breath, and cyanosis to ensure adequate oxygenation.
Choice D reason: Inserting an IV catheter is important for administering medications and fluids but comes after ensuring the client is receiving sufficient oxygen.
Correct Answer is A
Explanation
Choice A reason: Furosemide is a loop diuretic that can cause hypokalemia, so monitoring potassium levels is important.
Choice B reason: While calcium levels can be affected by furosemide, it is not typically the primary concern.
Choice C reason: Prothrombin time is not usually affected by furosemide and is not routinely monitored unless the patient is on anticoagulant therapy.
Choice D reason: Urine sodium could be checked, but it is the serum potassium that is most commonly monitored due to the risk of hypokalemia with furosemide use.
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