The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Engage the client in non-threatening conversations.

Encourage the client's family to visit more often.

Schedule a daily conference with the social worker.

Encourage the client to participate in group activities.

Answer and Explanation

The Correct Answer is A

Choice A reason: Engaging in non-threatening conversations can help the client feel more comfortable and may encourage communication, which is crucial for clients who are withdrawn due to depression.

Choice B reason: Family visits can be supportive, but the client's withdrawal suggests a need for more direct intervention to encourage communication.

Choice C reason: Scheduling a conference with a social worker is important, but it is not the most immediate intervention for a withdrawn client.

Choice D reason: Group activities may be overwhelming for a client who is noncommunicative and may not be the most suitable initial approach.

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Correct Answer is C

Explanation

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

A. Avoiding the use of sunscreen is important for adequate vitamin D synthesis. B. Vitamin D combined with calcium is balanced with phosphorus for absorption for strong bones. C. Calcium uses vitamin D that is produced in the skin by exposure to sunshine. D. Adding daily Vitamin D with oral calcium supplements promotes absorption of calcium into bone.

Correct Answer is D

Explanation

Choice A reason: Avoiding sunscreen is not recommended as it increases the risk of skin cancer; vitamin D can be obtained safely through diet and supplements.

Choice B reason: While it is true that vitamin D and calcium are balanced with phosphorus, this statement does not directly encourage compliance with supplementation.

Choice C reason: Although calcium uses vitamin D produced by sunlight exposure, relying solely on sunshine is not sufficient, especially for individuals at risk of osteoporosis.

Choice D reason: Emphasizing that vitamin D enhances calcium absorption into the bone provides a clear rationale for the client to comply with the supplementation regimen.

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The nurse notes that a client with depression has been more withdrawn and noncommunicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Correct Answer is C

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Correct Answer is D

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