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 A
Explanation
a. Verify the medication three times with the medication administration record.
When administering oral medications, the nurse should verify the medication three times with the medication administration record to ensure that the correct medication is being given to the correct client at the correct time. This is known as the "three checks" and is an important step in preventing medication errors.
Correct Answer is A
Explanation
Choice A Reason:
Determining the client's pattern for voiding. The reason why determining the client's pattern for voiding is the first step in implementing a bladder training program for a client who had a stroke is as follows:
Assessment: Before implementing any intervention, it's essential to assess the client's current bladder habits and patterns. Understanding when and how often the client typically voids, as well as any specific triggers or challenges they may have, is crucial information. This assessment helps the nurse create an individualized bladder training plan based on the client's unique needs.
Choice B Reason:
Assisting the client with relaxation techniques may be a helpful intervention in bladder training, but it should come after the assessment of the client's voiding pattern. Relaxation techniques can help the client manage urgency or anxiety related to bladder function, but they should be tailored to the client's specific needs.
Choice C Reason:
Discouraging intake of carbonated beverages is a dietary recommendation that can be a part of a bladder training plan, but it should be based on the client's assessment and preferences. It's important to assess the client's current fluid intake habits and any specific dietary triggers before making recommendations.
Choice D Reason:
Offering toileting opportunities every 1 to 2 hours is a potential intervention in a bladder training program, but it should also be based on the client's voiding pattern assessment. Implementing a toileting schedule without understanding the client's current habits may not be effective or necessary.
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