The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

"Are you the type of person who shares your problems easily?"

"What do you think is your primary goal to achieve this time?"

"Would you like me to sit with you for a while?"

"Have you experienced changes in your life recently?"

Answer and Explanation

The Correct Answer is C

Rationale:

A. "Are you the type of person who shares your problems easily?": This question explores communication style but may feel invasive or irrelevant to someone in acute distress. It does not directly address the client’s current emotional needs or offer support.

B. "What do you think is your primary goal to achieve this time?": Goal setting is important during the planning phase of care, but clients in overwhelming anxiety may not be ready for structured thinking. This question may increase pressure and exacerbate anxiety.

C. "Would you like me to sit with you for a while?": This offers immediate emotional support and conveys presence, which helps build trust and reduce anxiety. It is a therapeutic approach that meets the client’s most urgent need for calm and reassurance.

D. "Have you experienced changes in your life recently?": Life changes may contribute to anxiety, but exploring them is appropriate after the client feels emotionally safe and stable. The initial priority is to establish a calming presence, not to probe background stressors.

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Correct Answer is C

Explanation

Rationale:
A. Paresthesia of fingers due to carpal tunnel syndrome: Carpal tunnel symptoms typically progress slowly and are not life-threatening. While uncomfortable, they do not require urgent intervention unless accompanied by signs of severe nerve damage.

B. Burning pain due to a Morton’s neuroma: Morton’s neuroma causes localized nerve pain in the foot and may impair mobility, but it is not considered an emergency. It usually responds to conservative treatment and is not limb-threatening.

C. Sharp pain related to a crushed femur: A crushed femur can result in severe bleeding, compartment syndrome, or fat embolism—each of which can be life-threatening. Immediate assessment and intervention are critical to prevent complications like shock or loss of limb function.

D. Stinging pain related to plantar fasciitis: Plantar fasciitis causes chronic heel pain, especially with movement, but it is not emergent. It requires treatment for pain relief and inflammation but does not pose an immediate risk to life or limb.

A. A B. B C. C D. D E. None F. None

Correct Answer is D

Explanation

Rationale:

A: This shows the IV insertion site on the hand. While important for checking infiltration or phlebitis, it does not affect flow rate or volume delivered, so it's not the priority in fluid overload.

B: This shows the IV drip chamber. This is the first place to assess because it allows the nurse to determine how fast the IV fluid is infusing. It provides a quick visual cue of the actual flow rate, which is essential in evaluating whether the infusion is too fast, the likely cause of the overload.

C: This is the IV tubing near the insertion site. Kinks or dislodgement can affect flow, but it’s not the most immediate concern when fluid overload is suspected.

D: Shows the roller clamp, this directly controls the flow rate in a gravity system, so it is the place to intervene when fluid overload is suspected. After assessing the flow rate in the drip chamber and confirming fast infusion, the nurse should adjust the flow rate at this part.

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Focused Assessment Area	Clinical Finding
Musculoskeletal	Ambulates with a walker Flaccidity of left arm Passive range of motion of the left leg
Psychosocial	Fits of laughter Angry outbursts Tearful sharing of stories
Neurological	Drinks with repetitive cough Decorticate posturing Speaks in short sentences

The nurse is assessing a client who is experiencing overwhelming anxiety and difficulty performing self-care. Which question should the nurse ask first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse receives report on four clients who are reporting an increase in pain. Which client requires immediate intervention by the nurse?

Correct Answer is C

Explanation

A client is receiving IV fluids by gravity infusion and exhibits signs of fluid volume overload. When assessing the client's IV delivery system, where should the nurse assess first?

Correct Answer is D

Explanation

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