The client is a 26-year-old female who was in a car accident 6 months ago that killed her mother, husband, and 2-year-old

She and her father were the only survivors of the crash. She is seeking care for depression.

Click to highlight the areas that the nurse should react to immediately.

The client has returned to work at an accounting firm and has started going to a grief support group. She states she is seeking care from a healthcare professional because her father is worried about her. The client states she only gets 2-3 hours of sleep due to nightmares about the crash.

She states that exercising right after work helps her get better sleep and to relax. She feels that she is "jumpy after the accident, especially when she is in the car. She also stated, " feel so sad that I can't seem to feel anything at all." In addition to her father, the client has a large family and friend support system. She denies alcohol or drug use.

she only gets 2-3 hours of sleep due to nightmares about the crash

She feels that she is "jumpy after the accident

especially when she is in the car

feel so sad that I can't seem to feel anything at all

Answer and Explanation

The Correct Answer is ["A","B","C","D"]

Insufficient sleep, particularly due to nightmares, can exacerbate depression and should be addressed promptly.

Feeling "jumpy" or experiencing heightened anxiety, especially in situations reminiscent of the trauma, indicates a possible post-traumatic stress disorder (PTSD symptom.

A profound sense of sadness and numbness can be indicative of severe depression, requiring immediate attention.

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Correct Answer is C

Explanation

A. A 16-year-old client diagnosed with major depression who refuses to participate in group:

While refusal to participate may warrant assessment and intervention, it does not indicate immediate danger or escalation.

B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby: Pacing behavior may indicate anxiety or agitation, but it does not necessarily require immediate attention unless there are signs of escalating behavior or safety concerns.

C. An 18-year-old client with antisocial behavior who is being yelled at by other clients: Correct! The client with antisocial behavior being yelled at by other clients indicates a potential conflict or safety issue that requires immediate intervention to prevent escalation or harm to the client or others.

D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack: Refusal to eat is concerning in a client with anorexia nervosa, but it does not pose an immediate threat to safety compared to the situation involving potential conflict or aggression.

A. Assess pupillary response to light hourly. B. Initiate seizure precautions. C. Measure urinary output every hour. D. Monitor serum potassium frequently.

Correct Answer is C

Explanation

A. Assessing pupillary response to light is not directly related to the administration of dopamine for hypotension and does not reflect the immediate effects of the medication on the cardiovascular or renal systems.

B. Seizure precautions are not a standard intervention for a patient receiving dopamine unless the patient has a history of seizures or there is another indication for such precautions.

C. Measuring urinary output every hour is essential as it reflects the patient's fluid balance and kidney function, which can be affected by dopamine administration. It is a direct measure of the effectiveness of the medication in improving renal perfusion and the patient's hemodynamic status.

D. While monitoring serum potassium levels is important in patients receiving IV therapy, it is not the most immediate concern when administering dopamine for hypotension, unless the patient has a known electrolyte imbalance.

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Naxlex Comprehensive Predictor Exams

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Correct Answer is C

Explanation

A client who is hypotensive is receiving dopamine, an adrenergic agonist, IV at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is C

Explanation

A client with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?

The nurse is preparing a 50 mL dose of 50% Dextrose IV for a client with insulin shock. How should the nurse administer the medication?

The nurse is caring for a group of clients with the help of a practical nurse (PN) Which nursing action(s) should the nurse assign to the PN? (Select all that apply)

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement)

A client with obstructive sleep apnea (OSA ambulates in the hallway with the nurse prior to bedtime and then returns to bed. Which intervention is most important for the nurse to implement before leaving the client?

Exhibits What other medications would the nurse expect the surgeon to prescribe along with Morphine? Select all that apply.