A nurse is gathering data from a client who has severe anxiety. Which of the following findings should the nurse identify as an Indication that the client is experiencing a crisis?
Client isolates themselves from their family and friends
Client reports intermittent depressed mood
Client reports a decreased appetite
Client expresses an inability to experience pleasure
The Correct Answer is A
Choice A Reason:
Client isolates themselves from their family and friends. Isolating oneself from family and friends is an indication that the client is experiencing a crisis. Social withdrawal and isolation can be common responses to severe anxiety or a crisis situation. It suggests that the client is having difficulty coping with their anxiety or the stressor, and they may benefit from intervention and support.
Choice B Reason:
Reporting intermittent depressed mood may be indicative of a mood disorder but does not necessarily indicate a crisis.
Choice C Reason:
Reporting a decreased appetite can be a symptom of anxiety, but it is not specific to a crisis situation.
Choice D Reason:
Expressing an inability to experience pleasure is a symptom often associated with depression but does not provide specific information about the presence of a crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
There is no need to take a zinc supplement with timolol.
Choice B Reason:
"I should check my heart rate while taking this medication."This statement indicates an understanding of the teaching. Timolol is a beta-blocker eye drop used to lower intraocular pressure in clients with glaucoma. It can be systemically absorbed, and one of its potential side effects is bradycardia (slow heart rate). Therefore, clients taking timolol should be instructed to monitor their heart rate regularly, and if they notice a significant decrease in heart rate, they should notify their healthcare provider.
Choice C Reason:
Timolol does not typically darken the color of the eyes.
Choice D Reason:
Timolol does not dilate the eyes; it works to reduce intraocular pressure.
Correct Answer is A
Explanation
Choice A Reason:
Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.
Choice B Reason:
Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.
Choice C Reason:
Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.
Choice D Reason:
Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.
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