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
Choice A Reason:
Determine the client's pattern for voiding. Understanding the client's current voiding pattern and habits is essential in developing a personalized bladder training plan. This information helps in identifying when and how often the client typically voids, which is crucial for planning the timing of toileting opportunities and other interventions.
Choice B Reason:
Assisting the client with relaxation techniques may be part of the bladder training program but is not the first step. First, you need to assess the client's current voiding pattern to establish a baseline.
Choice C Reason:
Discouraging intake of carbonated beverages may also be part of the plan, but it's not the initial step. Assessment and establishing a baseline come first.
Choice D Reason:
Offering toileting opportunities every 1 to 2 hours is a key component of bladder training, but before implementing this, you should assess the client's current voiding pattern to determine if these
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.
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