Question

A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?

Answer 1

Correct Answers:

Risk for suicide

Rationale :

🔷 Expressions like "Why bother going on at all?" suggest hopelessness, a key indicator of suicidal ideation.

🔷 Bereavement can lead to complicated grief, but the presence of suicidal thoughts warrants immediate further assessment.

🔷 Early identification of suicide risk is critical to prevent self-harm or death.

🔷 The nurse should assess for plans, means, and intent to intervene appropriately.

🔷 Social isolation and chronic pain are concerns but less urgent than imminent suicide risk.

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Answer 2

Correct Answers:

Family history of anxiety disorders
Being a perfectionist
Excessive caffeine consumption
Chronic physical illness

Rationale :

Family history of anxiety disorders:

🔶 A positive family history indicates a genetic predisposition to anxiety disorders, increasing the client’s vulnerability.

🔶 Research shows that anxiety has a heritable component, often clustering in families.

🔶 This genetic risk interacts with environmental factors to influence disorder development.

🔶 Recognizing this helps in early identification and targeted interventions.

🔶 Family history is a non-modifiable but important risk factor.

Being a perfectionist:

🔶 Perfectionism is a personality trait linked to heightened anxiety and stress due to unrealistic standards and fear of failure.

🔶 It often leads to chronic worry and self-criticism, common in generalized anxiety disorder.

🔶 Such traits contribute to maladaptive coping and increased vulnerability to anxiety disorders.

🔶 Identifying perfectionism aids in tailoring cognitive-behavioral strategies.

🔶 It is a modifiable psychological risk factor.

Excessive caffeine consumption:

🔶 Caffeine is a central nervous system stimulant that can exacerbate anxiety symptoms.

🔶 High intake leads to increased heart rate, jitteriness, and nervousness, mimicking or worsening anxiety.

🔶 Clients with anxiety disorders are often advised to limit caffeine to reduce symptoms.

🔶 Monitoring and education about caffeine intake is an important nursing role.

🔶 This is a modifiable lifestyle factor.

Chronic physical illness:

🔶 Long-term illnesses such as diabetes, heart disease, or chronic pain impose ongoing physical and emotional stress, which can precipitate or worsen anxiety.

🔶 Physical illness can also cause biochemical changes that affect mood and anxiety regulation.

🔶 Clients may experience increased worry about health outcomes contributing to anxiety.

🔶 Management of chronic illness must include psychosocial support and anxiety screening.

🔶 This is a significant environmental risk factor.

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Answer 3

Correct Answers:

Combining medications that increase serotonin levels

Rationale :

🔵 Serotonin syndrome occurs from excess serotonin accumulation, often due to drug interactions.

🔵 Combining SNRIs with other serotonergic agents (e.g., MAOIs, triptans) increases risk significantly.

🔵 Symptoms include agitation, hyperreflexia, tremors, and can be life-threatening.

🔵 Missing doses or taking medications as directed typically do not cause syndrome.

🔵 Nurses should educate clients about avoiding multiple serotonergic drugs concurrently.

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Answer 4

Correct Answers:

The client makes a contract to avoid self-harm.

Rationale :

🔸 The immediate priority in depression after loss is ensuring client safety.

🔸 A contract to avoid self-harm indicates the client’s commitment to safety and reduces suicide risk.

🔸 Other goals like self-esteem and grieving are important but secondary to life preservation.

🔸 Contracting supports ongoing assessment and therapeutic alliance.

🔸 Nurses should continuously evaluate and reinforce safety plans.

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Answer 5

Correct Answers:

"It may take up to at least 2 weeks to see the effects of bupropion."

Rationale :

🔹 Antidepressants like bupropion require several weeks to produce noticeable therapeutic effects.

🔹 Clients should be educated to maintain adherence despite delayed onset to prevent premature discontinuation.

🔹 Drinking alcohol with bupropion is contraindicated due to seizure risk.

🔹 Bupropion does not typically cause bradycardia or increased salivation.

🔹 Correct understanding promotes safe and effective medication use.

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Answer 6

Correct Answers:

Stay with the client.

Rationale :

🔸 Panic attacks are frightening and overwhelming; the nurse's presence offers emotional support and reassurance.

🔸 Staying with the client helps reduce anxiety and feelings of isolation.

🔸 Leaving the client alone may exacerbate panic symptoms or lead to unsafe behaviors.

🔸 Escorting or restraint is not first-line unless safety is compromised.

🔸 Therapeutic presence fosters calm and grounding.

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Answer 7

Correct Answers:

Determine the presence and degree of suicidal risk.

Rationale :

🔷 Clients with depressive disorder and substance withdrawal have elevated suicide risk.

🔷 Assessment of suicidal ideation, plans, and means is critical for safety planning.

🔷 Other interventions are important but secondary to immediate risk assessment.

🔷 Early detection allows timely intervention and referral.

🔷 The nurse must prioritize life-saving assessments.

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Answer 8

Correct Answers:

The client eats 2 to 3 grams of sodium-containing foods daily.

Rationale :

🔵 Lithium levels are affected by sodium intake; low sodium can cause lithium retention and toxicity.

🔵 Clients must maintain consistent sodium consumption to avoid fluctuations in lithium blood levels.

🔵 High or low sodium intake can disrupt fluid and electrolyte balance, impacting lithium clearance.

🔵 Education on diet helps prevent toxic side effects like tremors, confusion, and seizures.

🔵 Nurses monitor serum lithium regularly to ensure safety.

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Answer 9

Correct Answers:

"I check any room I enter because the enemy is still after me and could be hiding anywhere."

Rationale :

🔸 This statement reflects hypervigilance and paranoia, classic symptoms of posttraumatic stress disorder (PTSD).

🔸 Clients with PTSD experience intrusive thoughts and heightened startle responses after trauma exposure.

🔸 Other options describe unrelated phenomena or delusions without PTSD context.

🔸 Early identification aids targeted therapeutic interventions.

🔸 Nurses provide support and safety strategies to address these symptoms.

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Answer 10

Correct Answers:

Identifying the client's support systems.

Rationale :

🔷 In a situational crisis, assessing the client’s existing support systems is vital to facilitate coping and recovery.

🔷 Support from family, friends, or community resources can buffer the effects of stress.

🔷 Understanding support availability helps nurses develop an effective care plan.

🔷 While coping skills and crisis cause are important, immediate support systems influence resilience.

🔷 Psychotic thinking is less common in situational crises unless comorbid disorders exist.

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QLexNursing

1 :
A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?

2 :
A nurse is educating the community about anxiety disorders. Which of the following should be included as predisposing factors for the development of anxiety disorders? (Select all that apply.)

3 :
Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Duloxetine, are used for generalized anxiety disorder. Which of the following increases the risk for the client developing serotonin syndrome?

4 :
A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

5 :
The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

6 :
A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

7 :
A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

8 :
A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

9 :
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

10 :
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

QLexNursing

1 : A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?

2 : A nurse is educating the community about anxiety disorders. Which of the following should be included as predisposing factors for the development of anxiety disorders? (Select all that apply.)

3 : Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Duloxetine, are used for generalized anxiety disorder. Which of the following increases the risk for the client developing serotonin syndrome?

4 : A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

5 : The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

6 : A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

7 : A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

8 : A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

9 : A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

10 : A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

1 :
A community health nurse is evaluating an elderly client whose wife passed away 4 weeks prior. The client mentions he is not eating and states, "Why bother, why bother going on at all?" Which of the following should the nurse recognize as the need for further assessment?

2 :
A nurse is educating the community about anxiety disorders. Which of the following should be included as predisposing factors for the development of anxiety disorders? (Select all that apply.)

3 :
Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as Duloxetine, are used for generalized anxiety disorder. Which of the following increases the risk for the client developing serotonin syndrome?

4 :
A nurse is planning care for a newly admitted client diagnosed with major depressive disorder following the loss of a child. Which of the following goals should the nurse identify as the priority?

5 :
The nurse is evaluating teaching for a client diagnosed with depression who is prescribed bupropion (Wellbutrin). Which of the following statements made by the client indicates that the teaching was effective?

6 :
A nurse is caring for a client with generalized anxiety disorder who is experiencing a panic attack. Which of the following is the nurse's priority action for this client?

7 :
A nurse is caring for a client diagnosed with a depressive disorder, who is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

8 :
A nurse is providing discharge teaching to a client diagnosed with bipolar disorder who will be discharged with a prescription for lithium. The nurse should teach the client that which of the following is a risk factor for lithium toxicity?

9 :
A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?

10 :
A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?