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 D

Explanation

Rationale:

A. A salad with three kinds of lettuce and fruit: While this meal is rich in vitamins and fiber, it lacks a significant source of protein necessary for wound healing. Leafy greens and fruits contribute micronutrients but provide minimal protein content.

B. A peanut butter sandwich with soda and cookies: Peanut butter contains some protein, but the overall meal is high in sugar and low in high-quality protein. The presence of soda and cookies further reduces the nutritional adequacy for promoting wound healing.

C. Vegetable soup, crackers, and milk: Milk does provide some protein, but the rest of the meal is low in protein-dense items. Vegetable soup and crackers are mostly carbohydrates and contribute very little to the client’s protein requirements.

D. A tuna fish sandwich with chips and ice cream: Tuna is a high-quality source of complete protein, which is essential for tissue repair. Though chips and ice cream are not ideal nutritionally, the inclusion of tuna makes this the most protein-rich option to support wound healing.

A. Assess level of consciousness and vital signs for both clients. B. Administered pain medication to the client with incisional discomfort. C. Complete a head-to-toe physical assessment for the client with pneumonia. D. Review the plan of care and the medications for both clients.

Correct Answer is A

Explanation

Rationale:
A. Assess level of consciousness and vital signs for both clients: This action prioritizes airway, breathing, and circulation (ABCs) and ensures prompt identification of any deterioration in either client's condition. It provides critical data needed to safely proceed with further interventions such as administering medications or conducting full assessments.

B. Administered pain medication to the client with incisional discomfort: While pain management is important, it is not the priority over initial assessment of both clients' status—especially the one on mechanical ventilation with an elevated temperature.

C. Complete a head-to-toe physical assessment for the client with pneumonia: A full assessment is essential, but it is not the most immediate action. Checking vital signs and neurological status first can quickly reveal urgent issues that might require rapid intervention.

D. Review the plan of care and the medications for both clients: This is necessary but should be done after determining the clients’ current conditions. Immediate physiological assessment takes precedence in critical care settings to prevent delays in interventions.

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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 has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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