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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. A diet low in phosphorus is not typically indicated for cirrhosis of the liver. Cirrhosis primarily affects the body's ability to handle proteins and not phosphorus.
B. Noting signs of swelling and edema is important as these are common complications of cirrhosis due to hypoalbuminemia and portal hypertension.
C. Increasing oral fluid intake is not advised as it can exacerbate fluid retention and ascites, which are complications of cirrhosis.
D. Monitoring abdominal girth is crucial for assessing changes in ascites and potential fluid overload.
E. Reporting serum albumin and globulin levels is essential as these can indicate the severity of liver disease and help guide treatment.
Correct Answer is C
Explanation
A. Provide bedside equipment for transmission and protective precautions: While infection control precautions are important, obtaining cultures to identify the source of infection and guide treatment is the priority in this scenario.
B. Evaluate daily serum electrolytes and hydration status: While monitoring electrolytes and hydration is important in critically ill patients, it is not the priority in this situation where the client is presenting with signs of systemic infection.
C. Culture sputum, urine, burn wound, and all intravenous access sites: The priority is to obtain cultures to identify the source of infection, which will guide antibiotic therapy and other
interventions.
D. Implement central line-associated bloodstream infection: While preventing central line- associated bloodstream infection is important, it is not the priority in this situation where the client is presenting with signs of systemic infection.
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