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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The shoulder harnesses of the car seat should be positioned at or slightly below the level of the infant's shoulders. This helps secure the infant properly in the car seat and provides appropriate protection in the event of a crash.

Car seats for infants should not be positioned at a 90° angle. Instead, they should be installed at a reclined angle, as recommended by the car seat manufacturer. The specific recline angle can vary depending on the car seat model and the age of the child.

Additional cushions or support devices should not be placed in the car seat unless specifically recommended by the car seat manufacturer. Extra padding or cushions can interfere with the proper fit of the harness and compromise the safety of the infant.

It is not safe to have an infant's car seat in the front seat if there is an active airbag. The safest place for an infant's car seat is in the rear seat, preferably in the middle position. If the car does not have a rear seat, it is important to disable the airbag if the car seat must be placed in the front seat.

A. Promoting trust B. Boundary crossing C. Veracity D. Countertransference

Correct Answer is A

Explanation

Rationale:
A. Promoting trust: Interrupting the bath to ensure the client receives nourishment demonstrates the nurse’s attentiveness, responsiveness, and prioritization of the client’s well-being. This action fosters a therapeutic relationship and builds trust between the nurse and client.

B. Boundary crossing: Boundary crossing occurs when a nurse engages in actions that deviate from professional limits, potentially for personal or emotional reasons. In this case, providing food to meet a basic client need does not constitute a boundary violation.

C. Veracity: Veracity refers to the ethical principle of being truthful with clients. While honesty is important in nursing, providing a meal to the client addresses their immediate physiological need rather than demonstrating truthfulness.

D. Countertransference: Countertransference happens when a nurse projects personal feelings onto a client, which can interfere with care. The nurse’s action here is intentional and focused on meeting the client’s needs, not influenced by personal unresolved emotions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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