A nurse is making judgments about problem status for a client with depression who has been receiving psychotherapy and antidepressant medication for 6 weeks. Which of the following statements should the nurse make?
"The problem is resolved because the client reports feeling happier and more hopeful.”.
"The problem is ongoing because the client still has suicidal thoughts and low self-esteem.”.
"The problem is improved because the client shows increased interest in social activities and hobbies.”.
"The problem is potential because the client is at risk for relapse and adverse effects of medication.". More questions on the topic.
The Correct Answer is C
Choice A reason:
This choice is incorrect because the problem is not resolved by the client's self-report of feeling happier and more hopeful. The nurse should assess other indicators of improvement, such as mood, affect, cognition, behavior, and functioning. Feeling happier and more hopeful may be a sign of progress, but it does not mean that the problem is completely resolved.
Choice B reason:
This choice is incorrect because the problem is not ongoing if the client has been receiving psychotherapy and antidepressant medication for 6 weeks. The nurse should expect some degree of improvement in the client's symptoms and functioning after this period of treatment. Suicidal thoughts and low self-esteem are serious concerns, but they may not reflect the current problem status of the client.
Choice C reason:
This choice is correct because the problem is improved if the client shows increased interest in social activities and hobbies. These are positive signs of recovery from depression, as they indicate that the client is experiencing more pleasure, motivation, and engagement in life. The nurse should acknowledge and reinforce these improvements, as well as monitor the client's response to treatment.
Choice D reason:
This choice is incorrect because the problem is not potential if the client has already been diagnosed with depression and is receiving treatment. The client is at risk for relapse and adverse effects of medication, but these are not problems that need to be addressed at this stage. The nurse should focus on evaluating the effectiveness of the current treatment plan and providing education and support to the client
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This statement is incorrect because it does not relate an outcome to an intervention. The client's weight loss may be due to increased diuretic therapy, but it is not clear how this is an outcome of the nurse's actions. A better statement would be: "The client's weight has decreased by 2 kg since discharge as a result of the nurse's education on diuretic therapy and daily weight monitoring.".
Choice B reason:
This statement is incorrect because it does not relate an outcome to an intervention. The client's dyspnea may be due to noncompliance with fluid restriction, but it is not clear how this is an outcome of the nurse's actions. A better statement would be: "The client's dyspnea has worsened despite the nurse's education on fluid restriction and sodium intake.".
Choice C reason:
This statement is incorrect because it does not relate an outcome to an intervention. The client's edema may have improved due to elevation of the lower extremities, but it is not clear how this is an outcome of the nurse's actions. A better statement would be: "The client's edema has improved as a result of the nurse's instruction on elevating the lower extremities and wearing compression stockings.".
Choice D reason:
This statement is correct because it relates an outcome to an intervention. The client's fatigue may have decreased due to participation in a cardiac rehabilitation program, which is an intervention that the nurse can facilitate or recommend for a client with heart failure. This statement shows that the nurse is evaluating the effectiveness of the intervention and the client's progress.
Correct Answer is A
Explanation
Choice A reason:
The nurse should compare the client's blood pressure readings with the expected outcomes to evaluate the effectiveness of the plan of care. This is the first step in the evaluation process, according to the nursing process framework. Comparing the actual outcomes with the expected outcomes allows the nurse to determine if the plan of care was successful or if it needs to be modified.
Choice B reason:
The nurse should identify the factors that influenced the client's blood pressure control, such as medication adherence, lifestyle changes, stress levels, and comorbidities. This is an important step in the evaluation process, but it is not the first one. The nurse should first compare the outcomes before analyzing the factors that affected them.
Choice C reason:
The nurse should document the results of the evaluation in the client's chart to communicate the findings to other members of the health care team and to provide evidence of quality care. This is also an essential step in the evaluation process, but it is not the first one. The nurse should document after comparing and analyzing the outcomes.
Choice D reason:
The nurse should modify the plan of care based on the evaluation findings to improve the client's blood pressure control and prevent complications. This is the final step in the evaluation process, after comparing, analyzing, and documenting the outcomes. The nurse should revise the plan of care as needed to meet the client's changing needs and goals.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.