A nurse notices that a client who has moderate anxiety is pacing the corridor and rambling. As the nurse approaches,the client states I am at the end of my rope. I don't think I can take any more bad news. Which of the following responses should the nurse make?
Rationale:
The nurse should say, "Come with me to an area where we can talk without interruption."
This response provides a safe, private environment for the client to express feelings and reduces external stimuli that may worsen anxiety. It demonstrates empathy and supports therapeutic communication, essential for clients experiencing moderate anxiety and emotional distress, facilitating trust and calming.
A: An anti-anxiety pill works best for situations like this. This option prematurely suggests medication without assessment or immediate therapeutic intervention, neglecting the client's need for support and communication first.
B: Most clients with anxiety issues benefit from lying down. Reclining might increase discomfort or fear in an anxious client and does not address the need for a calm, private space to process emotions.
C: Providers usually recommend relaxation exercises for clients who are as upset as you are. This statement generalizes treatment and misses the immediate need to establish safety and trust before suggesting coping strategies.
A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?
Rationale:
The client must be calm and cooperative before the nurse can remove the restraints. Restraints are used to ensure safety during aggressive behavior, and their removal depends on the client's behavioral stability, specifically when they demonstrate control and cooperation, indicating a reduced risk of harm to themselves or others. This criterion prioritizes safety and appropriate clinical judgment.
B: The client must verbalize remorse for their behavior does not guarantee safety or behavioral control, which is essential for restraint removal. Emotional expressions alone are insufficient to assess readiness for release.
C: The provider who prescribed the restraints must be present to assess the client before removal is not a required protocol; nurses can assess client status within their scope of practice.
D: The client only verbalizes anger toward the staff indicates ongoing agitation or potential risk; verbal anger does not meet the calm and cooperative standard necessary to safely remove restraints.
A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?
Rationale:
The nurse should secure the restraints using a quick-release tie. This method ensures rapid removal in emergencies while maintaining safety, preventing injury, and adhering to best practices for restraint application. Quick-release ties balance security with accessibility, allowing staff to act swiftly without compromising the client’s comfort or safety during restraint use.
A: Anticipating removal every 4 hours neglects more frequent assessments required to monitor circulation, skin integrity, and client safety, which must occur at least every 2 hours to prevent complications and ensure comfort.
B: Securing restraints to the lowest bar of the side rail risks injury if the rail moves; restraints should be attached to a stable part of the bed frame to avoid entrapment or falls.
D: Ensuring four fingers fit under restraints allows excessive looseness, increasing risk of slipping and ineffective restraint; the correct spacing is two fingers to balance prevention of constriction and mobility.
A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?
Rationale:
Weight gain is an expected finding in clients taking risperidone. Risperidone, an atypical antipsychotic, commonly causes metabolic side effects including increased appetite and weight gain. These effects result from alterations in glucose metabolism and lipid profiles. Monitoring weight is essential to prevent further complications such as diabetes or cardiovascular disease during risperidone therapy in schizophrenia management.
B: Bradycardia is not typically associated with risperidone use. This medication primarily affects dopamine and serotonin receptors without significant influence on heart rate regulation. Cardiovascular side effects generally include orthostatic hypotension, not slowed heart rate. Thus, bradycardia is an unlikely manifestation in patients taking risperidone for schizophrenia.
C: Nightmares are uncommon side effects of risperidone. While some antipsychotics affect sleep patterns, risperidone does not usually provoke vivid dreams or nightmares. Sleep disturbances more often manifest as sedation or insomnia, not specifically nightmares, making this an improbable expected finding.
D: Dependent edema is not a characteristic side effect of risperidone. Fluid retention related to this drug is rare; instead, orthostatic hypotension and weight gain from metabolic changes are more common. Dependent edema is more frequently linked to cardiovascular or renal conditions rather than risperidone therapy.
A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?
Rationale:
The client statement "My spiritual advisor has increased visits since I became ill" indicates spiritual distress. This reflects a heightened need for spiritual support due to illness, suggesting the client is struggling with spiritual concerns or uncertainty. Increased reliance on spiritual advisors often signals that the client is experiencing emotional or existential challenges related to their health or life situation.
A: Therapy is often scheduled during my daily meditation time. This highlights a scheduling conflict affecting spiritual practice, not distress. It reflects a practical issue rather than emotional or spiritual turmoil.
B: My faith gives me hope during difficult times. This statement demonstrates spiritual strength and resilience, showing that the client’s beliefs provide positive coping rather than distress.
C: I gain comfort from meditation. This shows the client uses meditation as a source of peace and support, indicating spiritual well-being, not distress or conflict.
A client with post-traumatic stress disorder (PTSD) experiences flashbacks. Which nursing intervention is most appropriate?
Rationale:
Teach grounding techniques. Grounding techniques help clients with PTSD manage flashbacks by redirecting their focus to the present moment, reducing dissociation and distress. This intervention empowers the client to regain control, promotes safety, and decreases anxiety without retraumatizing, making it a practical, evidence-based approach aligned with trauma-informed care principles in nursing practice.
B: Encourage detailed recounting of the trauma may exacerbate distress by triggering intense emotional responses, increasing vulnerability during flashbacks rather than providing immediate coping strategies or safety. This approach is better suited for controlled therapeutic settings, not acute nursing interventions.
C: Administer a PRN benzodiazepine risks dependence and sedation, potentially impeding coping skills development. Benzodiazepines do not address underlying PTSD symptoms and may worsen flashbacks or anxiety in some cases, making them unsuitable as first-line nursing interventions.
D: Avoid discussing the flashbacks neglects the client’s need for acknowledgment and support, potentially increasing isolation and fear. Ignoring symptoms can delay recovery and fails to provide necessary coping tools or emotional validation during distressing episodes.
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
Rationale:
Moderate anxiety often triggers physiological symptoms like urinary frequency due to heightened autonomic nervous system activity.
B: Urinary frequency reflects the body's stress response during moderate anxiety, involving increased sympathetic nervous system stimulation that affects bladder function, making it a typical symptom for clients experiencing this anxiety level.
A: Chills are more commonly associated with infections or temperature dysregulation, not typical physiological responses to moderate anxiety.
C: Rapid speech is a characteristic generally linked to mania or severe anxiety, not moderate anxiety where speech patterns remain more controlled.
D: Distorted perceptual fields occur in severe anxiety or psychosis, not in moderate anxiety where perception remains relatively intact.
The nurse is reviewing the laboratory findings for a 34-year-old woman who is scheduled for a Schilling's test for B12 deficiency anemia. Which result should the nurse report immediately to the primary care provider?
Rationale:
A positive pregnancy test should be reported immediately to the primary care provider. Pregnancy contraindicates the Schilling test due to potential harm from radioactive vitamin B12 used during the procedure. Prompt notification ensures appropriate modifications or postponement, protecting both maternal and fetal health while facilitating safe, alternative diagnostic approaches for B12 deficiency anemia.
B: Hemoglobin 9.5 g/dL and Hematocrit 32% indicate anemia but do not require immediate reporting before the Schilling test, as these results align with the clinical suspicion of B12 deficiency.
C: Glycosylated Hemoglobin (A1c) 7.5% reflects blood glucose control and is unrelated to the immediate safety concerns or diagnostic procedures for B12 deficiency anemia.
D: Serum Cholesterol 237 mg/dL shows elevated lipid levels but has no direct impact on the Schilling test or acute clinical decision-making in this context.
A nurse is caring for a client who has been brought into an emergency department of a large hospital. The client's family state that the client 'took some kind of drugs.' The client is dizzy, has recently vomited, and is experiencing paranoia, yelling, 'Stay away from me! You are going to kill me!' The client alternates yelling with mumbling and gesturing. Their eyes are darting back and forth as they are talking to the wall. The nurse should suspect the client has used which of the following substances?
Rationale:
The nurse should suspect the client has used hallucinogens.
Hallucinogens cause altered perceptions, paranoia, and hallucinations, which aligns with the client’s symptoms of yelling, mumbling, gesturing, and eyes darting. The combination of dizziness, vomiting, and psychotic behavior strongly indicates hallucinogenic intoxication rather than effects typical of other drugs.
A: Anabolic steroids produce mood swings and aggression but not hallucinations or paranoia evident here.
B: Opioids cause sedation and respiratory depression, contrasting with the client's hyperactive, paranoid state.
C: Stimulants increase alertness and agitation but do not typically cause hallucinatory experiences or intense paranoia shown here.
Vital Signs
Admission, 1600:
Temperature: 36.1° C (97° F)
Blood pressure: 98/66 mm Hg
Heart rate: 76/min
Respiratory rate: 10/min
Pulse oximetry: 95% on room air
Diagnostic Results
Blood alcohol level (BAC): 310 mg/dL (0 to 50 mg/dL)
History & Physical
Neurological: Client is intoxicated, has slurred speech, and is unable to coherently respond to questions.
Cardiovascular: Normal sinus rhythm and pulses palpable. No history of heart disease.
Respiratory: Chest clear to auscultation and no shortness of breath noted. No history of respiratory disorders and client states they quit smoking over 20 years ago.
Gastrointestinal: Client reports weight loss over the past 3 months and minimal appetite.
Genitourinary: Client reports no known problems.
Impression: Relapse of alcohol use disorder.
Plan: Admit for alcohol use disorder and observe for alcohol withdrawal.
Nurses' Notes
Client brought in by a family member who states that the client has been drinking “nonstop since the death of the client's parents 3 months ago.â€
Client has a history of alcohol use disorder for over 20 years.
Client attended an inpatient rehabilitation program 5 years ago and remained sober until several months ago when both parents died.
According to the client's family member, the client has been unable to cope with the sudden death of their parents.
Client is currently unemployed after being laid off.
Client's family member states, “Everything combined caused the drinking to start again.â€
Family member estimates the client's last drink was 2 hours ago.
A nurse in a mental health facility is admitting a client.Exhibits:Complete the following sentence by using the lists of options. The client is at risk for developing ___ as evidenced by the client's ___.
Rationale:
The client is at risk for developing alcohol withdrawal as evidenced by the client's history of alcohol consumption.
This option correctly identifies the risk of alcohol withdrawal due to the client's prolonged alcohol use and recent relapse after a period of sobriety. The history of heavy drinking and last drink two hours ago indicate impending withdrawal symptoms requiring monitoring and intervention in a mental health setting.
C: Seizures Seizures are a potential complication of withdrawal but are not directly evidenced by the client's current presentation or history at admission.
D: Unemployment Unemployment is a social factor but does not directly relate to the medical risk of withdrawal syndrome in this clinical context.
E: High Blood Alcohol Level A high blood alcohol level indicates intoxication but does not itself signify the risk of withdrawal developing.
F: Hallucinations Hallucinations may occur in severe withdrawal but are not reported or evident in the client’s initial assessment.
A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?
Rationale:
An appropriate nursing response is "Let's look at some other resources to solve this problem."
This response respects the nurse's professional boundaries while addressing the client's need by exploring alternative solutions. It promotes problem-solving and supports client autonomy, ensuring care within scope of practice. Offering resources aligns with ethical nursing practice and helps maintain the client's safety and well-being without performing prohibited tasks.
A: "I won't be able to shop for you today because I have to get home to my family." This response prioritizes personal reasons rather than professional boundaries or client needs, lacking empathy and failing to offer constructive assistance or alternative solutions.
B: "I would be happy to do whatever I can to help you." This statement is vague and may imply willingness to perform tasks outside scope, potentially encouraging inappropriate expectations without clarifying professional limits.
C: "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This advice dismisses the client’s current difficulties and does not address the immediate problem or explore supportive options, reducing client-centered care.
A nurse is assessing a client who has a history of alcohol use disorder. Which of the following questions should the nurse include to determine how alcohol use affects the client's psychosocial behaviors?
Rationale:
Direct Answer: "Has alcohol use affected your performance at work?"
Correct Option Explanation: This question directly explores the impact of alcohol on the client’s psychosocial functioning, specifically focusing on occupational performance. It assesses how alcohol influences daily responsibilities and social roles, which are critical elements of psychosocial behavior. Understanding work-related effects helps identify the extent of alcohol’s disruption in the client’s life and guides appropriate interventions.
B: "Have you received prior treatment for substance use disorder?" This question targets treatment history rather than current psychosocial behaviors, lacking focus on how alcohol presently affects social or occupational functioning.
C: "Do you receive treatment for any mental health disorders?" This query investigates comorbid mental health conditions but does not specifically address the psychosocial consequences of alcohol use itself.
D: "At what age did you begin drinking alcohol?" This question captures historical drinking patterns but does not provide information about the current psychosocial impact of alcohol use on the client’s behavior.
A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?
Rationale:
The nurse should document the client's behavior every 15 min. Frequent documentation ensures ongoing assessment of the client's physical and emotional status during seclusion, allowing timely identification of changes, risks, or needs, which supports safety and appropriate interventions while maintaining accurate legal and clinical records.
B: Obtain the provider's prescription within 60 min. This time frame is too long; prescriptions for seclusion typically require more immediate acquisition to comply with safety protocols and legal standards.
C: Monitor the client's vital signs every 4 hr. Monitoring every four hours is insufficient during seclusion when close observation is critical to detect rapid changes in health or distress.
D: Offer the client food and fluids every 2 hr. While nutrition is important, the priority during aggressive behavior seclusion is continuous observation and safety, not scheduled offering of food and fluids.
A nurse is caring for a client who has schizophrenia and diabetes mellitus. The nurse is reviewing a list of the client's prescribed medications and has questions about interactions. To which of the following members of the interprofessional team should the nurse direct their questions?
Rationale:
The nurse should direct their questions to the psychiatric pharmacist.
Psychiatric pharmacists specialize in medication management, including drug interactions and side effects, especially for clients with complex conditions like schizophrenia and diabetes mellitus. Their expertise ensures safe and effective pharmacological treatment, optimizing therapeutic outcomes while minimizing adverse effects and interactions among prescribed medications.
A: Laboratory technician Primarily handles specimen analysis and diagnostic testing, not medication interactions or clinical pharmacology, making them unsuitable for addressing complex drug-related questions.
C: Psychologist Focuses on behavioral therapies and mental health assessments, without authority or training to evaluate pharmacological interactions or medication management.
D: Primary provider While responsible for overall care, the provider relies on pharmacists for detailed drug interaction expertise, making the pharmacist the most appropriate resource for medication-specific inquiries.
A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?
Rationale:
The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is associated with feelings of fear. This circuit involves interconnected brain regions that regulate emotional responses, particularly fear processing. It plays a critical role in generating and modulating fear, which is a central neurophysiologic manifestation of anxiety. Understanding this circuit helps clarify anxiety symptoms linked to fear perception and response.
B: The amygdala-centered (ACC) circuit relates more to emotional regulation and conflict monitoring, not specifically to apprehension, which is a distinct emotional state involving worry rather than neural circuit activation.
C: The CSTC circuit is primarily linked to fear, not phobias, which are intense, irrational fears involving different neural pathways and conditioned responses beyond CSTC involvement.
D: The amygdala-centered (ACC) circuit does not solely govern panic; panic involves broader brain regions including the brainstem and autonomic nervous system, beyond the ACC’s primary functions.
A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture. Which one of the following should the nurse include in the plan of care?
Rationale:
Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. This topical anesthetic reduces pain and discomfort at the lumbar puncture site, making the procedure less distressing for the infant. It is crucial to apply it well before the procedure to ensure effective numbing and minimize procedural pain and anxiety.
A: Place the infant in an infant seat for 2 hr following the procedure restricts proper positioning; infants should lie flat or be held to prevent CSF leakage and headaches.
B: Hold the infant's chin to his chest and knees to his abdomen during the procedure actually describes the correct lumbar puncture positioning, not a planning care step.
C: Keep the infant NPO for 6 hr prior the procedure is unnecessary; lumbar punctures do not require prolonged fasting unlike some other invasive tests.
A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?
Rationale:
Encouraging physical activity for the client during the day helps alleviate symptoms of major depressive disorder by improving mood, increasing energy levels, and promoting better sleep patterns. Physical exercise stimulates endorphin release, which acts as a natural antidepressant, and supports overall mental health. Incorporating activity into the care plan encourages engagement and counters the lethargy often associated with depression.
A: Discouraging the client from expressing feelings of anger limits emotional release and hinders therapeutic communication, which is essential for processing emotions and achieving mental health improvement in depression treatment.
B: Identifying and scheduling alternative group activities may not directly address the client’s energy deficits or mood symptoms; individualized interventions like physical activity more effectively target depressive symptoms.
D: Keeping a bright light on at night disrupts normal circadian rhythms and sleep quality, potentially exacerbating depressive symptoms rather than providing therapeutic benefit.
A client tells the nurse,"I feel bad because my mother does not want me to return home after I leave the hospital. Which nursing response is most therapeutic?
Rationale:
Direct Answer: You feel that your mother does not want you to come back home.
Correct Option Explanation: This response reflects therapeutic communication by validating the client’s feelings without judgment or interpretation. It encourages further discussion and emotional expression, demonstrating empathy and understanding. By restating the client’s concern, the nurse creates a supportive environment that fosters trust and openness, essential for effective therapeutic relationships and emotional healing.
A: Your mother seems like an understanding person. I'll help you approach her. This assumes the mother’s feelings without client confirmation, potentially invalidating the client’s emotions and shutting down honest dialogue.
B: It's quite common for clients to feel that way after a lengthy hospitalization. This minimizes the client’s unique experience and feelings, offering a general statement that may feel dismissive rather than supportive.
C: Why don't you talk to your mother? You may find out she doesn't feel that way. This challenges the client’s perception and can cause defensiveness, hindering emotional expression and therapeutic rapport development.
A nurse is caring for a group of clients at a mental health facility. The nurse should identify that which of the following clients is exhibiting a warning sign of suicide?
Rationale:
A client who is giving away their possessions is exhibiting a warning sign of suicide. Giving away belongings often indicates preparation for death, reflecting a sense of finality and detachment from life, which are critical indicators of suicidal intent. This behavior signals that the client may be planning self-harm and requires immediate assessment and intervention to ensure safety.
A: A client who states that they are stopping their medication reflects noncompliance but not a direct indicator of suicidal ideation or immediate risk.
B: A client requesting an appointment to discuss depression shows help-seeking behavior, which suggests engagement rather than imminent suicide risk.
C: A client who reports sleeping 12 hours daily indicates possible depression or fatigue, but excessive sleep alone does not directly imply suicidal warning signs.
A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, 'I think my blackouts are actually caused by low blood sugar.' The nurse should recognize the client is using which of the following defense mechanisms?
Rationale:
The client is using rationalization. Rationalization involves creating logical reasons to justify unacceptable feelings or behaviors, such as attributing blackouts to low blood sugar instead of acknowledging the psychological origins of dissociative identity disorder symptoms. This defense mechanism helps the client avoid confronting the distressing reality by offering a more acceptable explanation for their experiences.
A: Suppression involves consciously choosing to delay paying attention to a distressing thought, which doesn't apply since the client is explaining, not avoiding, the blackouts.
B: Sublimation redirects unacceptable impulses into socially acceptable activities, unlike the client who is justifying symptoms rather than channeling feelings constructively.
C: Projection attributes one’s own unacceptable thoughts to others, but the client is blaming a physiological cause, not misplacing internal feelings onto someone else.
A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?
Rationale:
The nurse should say, "We are concerned about you and need to keep you safe." This response acknowledges the client’s feelings while emphasizing the priority of safety, establishing trust, and justifying close supervision without threatening or dismissing the client’s concerns, which is essential in managing suicidal ideations and preventing self-harm effectively.
A: If you complete a contract that states you will not harm yourself, you can be alone. This option falsely assumes that a signed contract guarantees safety, which overlooks the unpredictable nature of suicidal behavior requiring continuous assessment rather than reliance on agreements.
B: Until your medication has reached therapeutic levels, you will need constant observation. This statement incorrectly focuses solely on medication effects, neglecting immediate safety concerns and the necessity of observation based on current risk rather than medication status.
C: Since you are trying to follow the treatment plan, we can submit your request to the provider. This response misplaces priority by deferring the client’s urgent safety needs to provider approval instead of addressing immediate risk and the necessity of protective measures.
All are negative symptoms of schizophrenia except
Rationale:
Delusions are not negative symptoms of schizophrenia.
Delusions represent positive symptoms characterized by false beliefs and distorted thinking, reflecting an excess or distortion of normal functions. Negative symptoms involve diminished emotional expression, motivation, and speech, such as avolition, apathy, and alogia, which denote deficits or reductions in typical behaviors and mental processes rather than additions or exaggerations.
A: Delusions involve false beliefs and are positive symptoms, representing excesses rather than deficits in function.
B: Avolition signifies a reduction in goal-directed behavior, a core negative symptom characterized by lack of motivation.
C: Apathy refers to diminished emotional responsiveness, fitting the negative symptom profile of reduced affect.
D: Alogia involves poverty of speech, reflecting decreased verbal output and cognitive slowing typical of negative symptoms.
A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?
Rationale:
Implement measures to prevent intentional self-inflicted injury. This strategy is paramount because clients with borderline personality disorder have a high risk of self-harm and suicide attempts. Prioritizing safety addresses immediate physical risks, stabilizes the client, and creates a foundation for further therapeutic interventions. Ensuring protection from self-injury is essential before focusing on behavioral or emotional strategies.
A: Encourage the client to attend weekly support group meetings. While helpful for social support and coping, this approach does not address the immediate risk of self-harm and therefore is not the priority in initial safety planning.
B: Discuss the appropriate use of assertive behavior with the client. Teaching assertiveness aids communication skills but neglects urgent safety concerns related to self-injury, which require immediate intervention to prevent harm.
D: Assist the client to maintain awareness of their thoughts and feelings. Enhancing self-awareness supports emotional regulation but does not directly prevent imminent risks of self-inflicted injuries, which takes precedence in care planning.
A nurse is caring for a client with a diagnosis of depression. A decrease in which of the following neurotransmitters has been implicated in depression?
Rationale:
A decrease in norepinephrine and serotonin has been implicated in depression. These neurotransmitters regulate mood, emotion, and cognition, and their deficiency is closely linked to depressive symptoms. Many antidepressants target the reuptake or breakdown of these chemicals to restore balance, improving mood and alleviating depression-related impairments in brain function and emotional regulation.
A: Gamma-aminobutyric acid (GABA) and acetylcholine GABA primarily inhibits neural activity, and acetylcholine influences muscle activation and memory, but their decreases are not typically associated with depression’s core neurochemical deficits.
B: Glutamate and histamine Glutamate is excitatory and histamine regulates wakefulness, yet neither neurotransmitter’s reduction is predominantly linked to depression’s pathophysiology.
D: Serotonin and acetylcholine Serotonin’s decrease is relevant, but acetylcholine’s role pertains more to memory and autonomic functions, making this combination less accurate for depression’s neurochemical changes.
A nurse is discussing treatment of depressive disorders with a client who has major depression. Which of the following client statements indicates understanding of the teaching?
Rationale:
Attending psychotherapy to help manage depression indicates understanding of the treatment for major depressive disorder. Psychotherapy is a key component in managing depression alongside medication, providing coping strategies and emotional support. It addresses underlying issues and helps clients develop skills to manage symptoms effectively over time, making it an essential part of comprehensive treatment.
A: I can be on my antidepressant taking three to five days to be effective. Antidepressants typically require several weeks to show significant therapeutic effects, not just a few days, so this statement misrepresents expected medication timelines.
B: I can cure my depression by thinking positive thoughts. Positive thinking alone does not cure depression; it requires professional treatment and often medication, making this belief overly simplistic and misleading.
D: I need to make a voluntary choice to stop feeling depressed. Depression is a medical condition beyond simple willpower, so choosing to stop feeling depressed voluntarily ignores the complexity of the disorder.
A nurse is preparing to teach a client about the lithium prescription for treating bipolar disorder. Which of the following statements should the nurse include in the teaching?
Rationale:
You should maintain adequate sodium intake and you will need your blood levels drawn weekly during the first month. Lithium requires stable sodium levels to avoid toxicity or subtherapeutic effects, and frequent blood monitoring is essential initially to ensure safe, therapeutic lithium concentrations and prevent adverse effects. These instructions promote effective and safe treatment for bipolar disorder with lithium.
A: Nausea, vomiting, and diarrhea can indicate lithium toxicity and must be reported immediately, making this statement misleading and potentially dangerous for patient safety during lithium therapy.
C: Taking lithium on an empty stomach is not advised as it can increase gastrointestinal upset; usually, it is recommended to take lithium with food to minimize stomach irritation.
Nurse Notes
Today, 0800:
Urgent Care
Client reports feeling very anxious and states they have a terrible headache. The client is diaphoretic and rates headache as 9 on a 0 to 10 numeric pain scale. Client was evaluated by provider and was transferred by emergency medical services to the emergency department
Today, 0900
Emergency Department
The client states “I went to urgent care this morning because had a terrible headache. I thought it might be a migraine. They told me my blood pressure was too high, so they sent me here" Client reports having sinus issues and taking over the counter decongestants for the past few days. Client also states, "last week my provider changed my medication from paroxetine to phenelzine and my depression is decreasing.â€
Client appears nous restless, Breath sounds clear and equal.
Heart sounds S1, S2, no murmur. Skin is warm to touch, very diaphoretic
Client reports headache as a 10 on a 0 to 10 numeric pain scale
Vital Signs
Today, 0800
Urgent Care
Blood Pressure: 191/92 mmHg
Heart Rate: 104/min
Respiratory Rate: 18/min
Temperature: 39.2°C (1026°F)
Oxygen saturation 95% on room air
Today, 0900:
Blood Pressure 197/99mmHg
Heart Rate: 108/min
Respiratory Rate: 20
Temperature: 39.6"(103.2°F)
Oxygen saturation: 93% on room air
Complete the following sentence by using the list of options. The nurse should plan to administer ____ and ____.
Rationale:
The nurse should plan to administer intravenous phentolamine and apply a cooling blanket to the client.
Intravenous phentolamine is essential to rapidly lower dangerously high blood pressure, preventing hypertensive crisis complications. Applying a cooling blanket helps reduce the client's elevated temperature, addressing hyperthermia indicated by fever and diaphoresis. Together, these interventions target the urgent clinical signs of hypertensive emergency and fever management.
C: Oral benztropine treats extrapyramidal symptoms, unrelated to hypertensive crisis or fever control in this scenario.
D: Oral valbenazine manages tardive dyskinesia, which is not indicated by the client’s acute presentation.
E: Intravenous diphenhydramine addresses allergic reactions or extrapyramidal symptoms, not hypertension or fever here.
F: Suicide precautions are not immediately relevant, as no suicidal ideation or behavior is documented.
G: Checking the absolute neutrophil count monitors for agranulocytosis, irrelevant to the current hypertensive emergency and fever.
A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?
Rationale:
Planning a menu with the client supports their involvement in managing binge eating disorder. This collaborative approach promotes healthy eating habits, encourages self-control, and helps identify triggers. It empowers the client to make mindful food choices, fostering a structured eating routine essential for recovery and reducing episodes of uncontrolled binge eating over time.
A: Weigh the client every other day. Frequent weighing can increase anxiety and body image concerns, potentially worsening binge eating behaviors rather than promoting recovery or self-efficacy.
B: Remain with the client for 1 hr after meals. This action is more relevant for disorders involving purging, not binge eating disorder, where monitoring post-meal behavior is less critical.
C: Offer snacks when the client is hungry. Providing snacks without structure may encourage impulsive eating and binge episodes, undermining efforts to establish controlled, balanced eating patterns.
A nurse is discharging a client who was admitted for the treatment of alcohol withdrawal. Which of the following resources should the nurse recommend to the client?
Rationale:
12-step program is the recommended resource for a client recovering from alcohol withdrawal, as it provides structured peer support and a proven framework for maintaining sobriety. This approach emphasizes accountability, community, and ongoing recovery, which are essential for preventing relapse and promoting long-term abstinence from alcohol.
A: Reach to recovery primarily supports cancer survivors and is unrelated to alcohol withdrawal recovery, making it an unsuitable recommendation for this client’s needs.
C: Al-Anon offers support for family members of individuals with alcohol use disorders, not for the recovering individual themselves.
D: Light therapy is used to treat seasonal affective disorder and depression, having no relevance to alcohol withdrawal or recovery support.
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.†The nurse identifies this behavior as an example of which of the following defense mechanisms?
Rationale:
This behavior is an example of regression. Regression involves reverting to an earlier developmental stage when faced with stress, demonstrated by the client’s dependence and neglect of responsibilities, reflecting a childlike need for care and avoidance of adult tasks.
A: Dissociation involves detaching from reality or memories, which does not align with the client’s expressed need for care or neglect of chores.
B: Introjection refers to internalizing others’ beliefs or values, not the client’s dependent and avoidant behavior shown here.
D: Repression is the unconscious blocking of distressing thoughts, unlike the observable childish behavior and verbal admission of stress.
The nurse is providing care for a client diagnosed with dissociative fugue. Which behaviors would the nurse expect to see with this client?
Rationale:
Sudden unexpected travel or confused wandering is characteristic of dissociative fugue. This disorder involves abrupt, unplanned travel away from home with an inability to recall personal identity or past events. Clients may appear confused about their location or personal history, reflecting the hallmark dissociative symptom of fugue states disrupting normal awareness and memory integration.
A: Clinically significant distress in occupational functioning describes general impairment but does not specifically capture the hallmark feature of dissociative fugue, which centers on travel and identity confusion rather than occupational symptoms.
C: An inability to recall a parent’s contact information is too narrow and does not encompass the extensive memory loss or travel behaviors typical of dissociative fugue episodes.
D: Occasional periods of forgetfulness indicate mild memory lapses, unlike the profound amnesia and travel characteristic of dissociative fugue, which involves sudden identity disruption and displacement.
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?
Rationale:
The client uses this behavior to decrease anxiety to a tolerable level. This repetitive action serves as a coping mechanism to reduce distress caused by obsessive thoughts. By engaging in compulsive behaviors, the client temporarily alleviates internal tension and gains a sense of relief, which is characteristic of OCD symptom management and helps maintain emotional equilibrium.
A: Limit the amount of time available to interact with others. This option misinterprets the behavior as social avoidance rather than anxiety reduction. The client’s actions are driven by internal distress, not a desire to reduce social contact or isolate themselves.
C: Focus attention on meaningful tasks. The behavior is not directed toward purposeful or productive activities but rather repetitive actions aimed at anxiety relief. It lacks meaningful goal orientation typical of focused task engagement.
D: Manipulate and control others' behaviors. The client’s compulsive picking is self-directed and anxiety-driven, not intended to influence or control others. This option confuses personal coping strategies with interpersonal manipulation.
A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?
Rationale:
D: We are concerned about you and need to keep you safe. This statement acknowledges the client’s feelings while emphasizing safety, fostering trust and therapeutic rapport. It transparently communicates the nurse’s priority without making promises or conditions, which is essential when managing suicide risk and ensuring the client understands the reason for constant supervision.
A: Until your medication has reached therapeutic levels, you will need constant observation. This focuses solely on medication timing, neglecting the immediate risk and emotional support needed during suicidal ideation, thus lacking relevance to the client’s current safety needs.
B: Since you are trying to follow the treatment plan, we can submit your request to the provider. This implies negotiation and delays safety measures, which is inappropriate for imminent suicide risk and does not address the urgency of constant observation.
C: If you complete a contract that states you will not harm yourself, you can be alone. Relying on a no-harm contract is insufficient protection during active suicidal ideations and ignores the necessity for continuous supervision to prevent harm.
A nurse is caring for a client who is depressed and refuses to participate in group therapy or perform activities of daily living. Which of the following statements should the nurse make to the client?
Rationale:
The nurse should say, "I will assist you in getting out of bed and getting dressed."
This statement offers direct support and encouragement, promoting client autonomy while gently motivating participation. It demonstrates empathy and a willingness to help, which can reduce resistance. This approach aligns with therapeutic communication principles, fostering trust and cooperation without imposing demands or ultimatums, essential for clients struggling with depression.
A: The unit rules state that you may not remain in bed. This statement imposes strict rules that may increase resistance and feelings of punishment, lacking empathy and support.
B: You can remain in bed until you feel well enough to join the group. This allows prolonged inactivity, potentially reinforcing depressive withdrawal and not encouraging engagement or recovery.
D: If you don't participate in your care, you will not get better. This threat could increase guilt or anxiety, damaging rapport and failing to provide supportive encouragement needed for motivation.
A nurse on a crisis hotline is speaking to a client who says, 'I just took an entire bottle of amitriptyline.' Which of the following responses should the nurse make?
Rationale:
The nurse should respond with, "I'm glad you called, and I want to send an ambulance to help you." This response acknowledges the client’s courage in reaching out, conveys empathy, and immediately prioritizes safety by arranging emergency assistance, which is critical in an overdose situation. It demonstrates support without judgment and focuses on prompt intervention to prevent harm.
B: You must have been feeling pretty depressed to do that. This response risks sounding judgmental and may increase the client’s feelings of guilt or shame, potentially discouraging further communication or honesty.
C: Were you trying to kill yourself by taking an overdose? This question is confrontational and may cause defensiveness or withdrawal, which can hinder rapport and delay necessary emergency actions in a crisis situation.
D: Do you know how many pills were in the bottle? This inquiry delays urgent intervention by focusing on details rather than immediate safety and emotional support, which are paramount during a crisis call.
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
Rationale:
Administer a medication such as benztropine IM to correct this dystonic reaction.
Benztropine, an anticholinergic, effectively treats acute dystonic reactions caused by first-generation antipsychotics like haloperidol by reducing muscle rigidity and spasms. Kyle’s symptoms—stiffness, inability to respond, and vital sign changes—indicate an urgent dystonic crisis needing immediate pharmacological intervention to prevent further complications and improve his condition rapidly.
A: Hold his medication and contact his prescriber. This delays immediate symptom relief and does not address the acute dystonia requiring prompt treatment to prevent worsening muscle rigidity and potential airway compromise.
B: Wipe him with a washcloth wet with cold water or alcohol. This action only provides superficial comfort and fails to alleviate the serious neurological muscle symptoms or autonomic instability Kyle is exhibiting.
D: Reassure him that although there is no treatment for his tardive dyskinesia, it will pass. Kyle’s presentation is acute dystonia, not tardive dyskinesia, which requires active intervention rather than passive reassurance alone.
A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The client is doing calisthenics in the client dining room during lunchtime instead of eating. Which of the following statements should the nurse make?
Rationale:
Come with me. Here is a milkshake to drink. This statement redirects the client calmly while addressing their immediate nutritional needs, offering a high-calorie drink to prevent further weight loss and exhaustion. It respects the client’s autonomy and provides a gentle intervention without confrontation, which is essential in managing acute mania and promoting safety and nourishment.
B: We need you to decide what activities you will do today lacks immediate intervention and does not address the client’s current unmet nutritional needs or manic behavior, making it impractical during acute mania.
C: You will need to leave the dining room right now and go somewhere else to exercise ignores the client’s need for nutrition and may escalate agitation by demanding abrupt relocation without support.
D: You are already too thin and exercise is not good for you. Go sit down somewhere and eat something uses negative judgment and commands, which can increase resistance and anxiety instead of fostering cooperation or safety.
A nurse is assessing a client who has bipolar disorder. Which of the following findings should the nurse identify as an indication that the client is experiencing acute mania?
Rationale:
Reports a lack of sleep indicates the client is experiencing acute mania. During acute mania, individuals often exhibit decreased need for sleep without feeling tired, reflecting heightened energy and activity levels. This symptom is a hallmark of manic episodes in bipolar disorder and helps distinguish mania from other mood states or psychiatric conditions where sleep patterns differ significantly.
A: Writes a detailed daily activity schedule reflects organized behavior, which contrasts with the disorganized, impulsive, and erratic actions typical of acute mania.
B: Refuses to engage in conversation suggests withdrawal or depression, not the talkative, pressured speech characteristic of manic episodes.
C: Isolates self from others indicates social withdrawal, more aligned with depressive phases, rather than the increased sociability and hyperactivity seen in mania.
A nurse is caring for a client who has a new diagnosis of major depressive disorder. Which of the following medications should the nurse expect the provider to prescribe to the client as a first-line treatment?
Rationale:
Fluoxetine is the medication the nurse should expect as a first-line treatment for major depressive disorder. It is a selective serotonin reuptake inhibitor (SSRI) widely prescribed for its efficacy in improving mood and reducing depressive symptoms. SSRIs are preferred due to their favorable side effect profile and safety compared to other antidepressants, making fluoxetine a standard initial choice.
A: Midazolam is a benzodiazepine primarily used for sedation and anxiety, not depression, thus it does not address the core symptoms of major depressive disorder or serve as a first-line antidepressant treatment.
C: Cyclobenzaprine is a muscle relaxant utilized for musculoskeletal conditions and lacks antidepressant properties, making it irrelevant for treating major depressive disorder.
D: Valproic acid is an anticonvulsant and mood stabilizer used mainly for bipolar disorder or seizure control, not as a primary medication for initial major depressive disorder management.
A nurse is reviewing the medical record of a newly admitted client who has major depressive disorder. Which of the following findings should the nurse identify as a risk factor for this condition?
Rationale:
A: The client has a serotonin deficiency. Serotonin deficiency is a well-established biological factor contributing to major depressive disorder by affecting mood regulation and emotional stability. Imbalances in neurotransmitters, particularly serotonin, influence depressive symptoms, making this a key risk factor identified in clinical and research settings related to depression onset and progression.
B: The client has acute bronchitis. Acute bronchitis is a temporary respiratory infection unrelated to the neurochemical or psychological causes of major depressive disorder, thus it does not represent a direct risk factor for this mental health condition.
C: The client has an elevated calcium level. Elevated calcium levels typically indicate metabolic or endocrine issues, such as hyperparathyroidism, which are not directly linked to the development or risk of major depressive disorder.
D: The client is an only child. Being an only child does not inherently increase the risk for major depressive disorder, as familial structure alone lacks direct causative association with this psychiatric diagnosis.
Which of the following factors increases a client's risk of experiencing a crisis?
Rationale:
A history of trauma increases a client's risk of experiencing a crisis. Past traumatic experiences can create underlying vulnerabilities and emotional instability, making individuals more susceptible to overwhelming stress or crisis situations. Trauma often impairs coping mechanisms and resilience, leading to heightened sensitivity to future adverse events and difficulties in managing emotional responses effectively during challenging times.
A: Stable employment indicates consistent income and routine, providing financial security and emotional stability, which lowers the likelihood of encountering a crisis by reducing stressors related to job insecurity and economic hardship.
B: Positive coping skills enable individuals to manage stress and adversity effectively, enhancing resilience and preventing escalation into crisis. These skills promote adaptive responses and emotional regulation during difficult circumstances.
D: Strong social support systems offer emotional assistance, practical help, and a sense of belonging, buffering stress and mitigating the risk of crisis by providing resources and encouragement during challenging periods.
A nurse is assessing a client in an inpatient mental health unit. Which of the following findings should the nurse expect if the client is in the preassaultive stage of violence? (Select all that apply.)
Rationale:
Defensive responses to questions, agitation, and facial grimacing are expected findings in the preassaultive stage of violence. These behaviors indicate escalating tension and potential aggression as the client becomes defensive, restless, and expresses discomfort or anger through facial expressions, signaling a heightened risk for violent outbursts if not properly managed or de-escalated in time.
B: Lethargy reflects decreased energy and responsiveness, which contrasts with the heightened arousal and tension characteristic of the preassaultive stage, making it an unlikely manifestation of impending violence.
C: Disorientation involves confusion and impaired awareness, typically relating to cognitive dysfunction rather than the focused agitation and defensive posture observed in the preassaultive phase of violence.
A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. Findings include blood pressure changes, hyperpyrexia, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?
Rationale:
Neuroleptic malignant syndrome is the adverse effect occurring with blood pressure changes, hyperpyrexia, and diaphoresis in a client on multiple antipsychotics. This life-threatening condition involves severe muscle rigidity, altered mental status, autonomic dysfunction, and elevated temperature. Prompt recognition and treatment are critical to prevent complications. The symptoms align closely with neuroleptic malignant syndrome rather than other extrapyramidal symptoms.
A: Pseudoparkinsonism involves rigidity, bradykinesia, and tremors but lacks severe hyperpyrexia and autonomic instability, making it inconsistent with the acute presentation described.
C: Acute dystonia presents as sudden muscle contractions and spasms without the systemic signs of fever and blood pressure fluctuations seen here.
D: Tardive dyskinesia manifests as involuntary repetitive movements developing after prolonged therapy, not with sudden onset of fever or autonomic symptoms.
The client has been diagnosed with a depressive disorder. Which statement by the client indicates an understanding of this disorder?
Rationale:
The statement "With this disorder, I will not experience mania" indicates an understanding of depressive disorder. This is accurate because depressive disorders involve persistent feelings of sadness or loss of interest without manic or hypomanic episodes, distinguishing them from bipolar disorders where mania occurs. Recognizing this difference reflects correct knowledge about the nature of depressive disorders.
A: The depressive symptoms indicate I'm bipolar. This conflates depressive disorder with bipolar disorder, overlooking the absence of manic episodes in depressive disorders, thus demonstrating a misunderstanding of the diagnosis.
C: Depression is a one-time incident only. This disregards the recurrent nature of depressive disorders, which often involve multiple episodes, indicating an inaccurate perception of the disorder’s chronic or episodic course.
D: I may experience episodes of hypomania. Hypomania is characteristic of bipolar spectrum disorders, not depressive disorders, so this statement incorrectly attributes symptoms that do not occur in depressive disorder.
A nurse is caring for a client with an eating disorder. Which safety considerations should the nurse prioritize for a client with Binge eating disorder? (Select All that Apply.)
Rationale:
Monitoring the client's food intake and ensuring a balanced diet, and encouraging the client to engage in regular physical activity are essential safety considerations for a client with Binge Eating Disorder. These strategies help manage binge episodes, promote healthy nutrition, and support physical and emotional well-being, reducing the risk of obesity and related health complications commonly seen in this disorder.
B: Allowing unrestricted access to food increases the likelihood of binge episodes, exacerbating the disorder and hindering recovery by removing necessary boundaries and control over eating habits.
D: Ignoring signs of distress or emotional triggers neglects the psychological aspects crucial to binge eating disorder management, preventing timely intervention and worsening emotional and behavioral symptoms.
E: Minimizing the importance of regular therapy sessions disregards the vital role professional support plays in addressing underlying issues, emotional regulation, and relapse prevention in binge eating disorder treatment.
A nurse is reviewing a client's medication list. Which medication has been indicated for improvement in cognitive functioning in mild to moderate Alzheimer's disease?
Rationale:
Galantamine (Razadyne) is indicated for improving cognitive functioning in mild to moderate Alzheimer's disease. Galantamine enhances cholinergic function by inhibiting acetylcholinesterase and modulating nicotinic receptors, which helps alleviate cognitive symptoms. This dual mechanism supports memory, attention, and overall cognition, making it appropriate for managing Alzheimer's-related cognitive decline compared to other medications listed here.
A: Clozapine (Clozaril) primarily treats schizophrenia and has no established role in cognitive improvement in Alzheimer's disease, focusing instead on psychotic symptoms and not on cholinergic enhancement.
C: Olanzapine (Zyprexa) is an antipsychotic used for schizophrenia and bipolar disorder, not for cognitive enhancement, and it may worsen cognitive impairment in Alzheimer's patients.
D: Sertraline (Zoloft) is an SSRI antidepressant targeting mood disorders, lacking efficacy in improving cognition or memory deficits associated with Alzheimer's disease.
A nurse is caring for a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
Rationale:
Restlessness is a common manifestation of opioid withdrawal. During withdrawal, the nervous system becomes hyperactive, causing symptoms like agitation, anxiety, and restlessness. These signs result from the body's adjustment to the absence of opioids, which initially suppressed nervous system activity. The client often experiences increased motor activity and irritability, reflecting the central nervous system's rebound effect after opioid discontinuation.
A: Bradycardia reflects slowed heart rate, which contrasts with withdrawal’s typical tachycardia. Opioid withdrawal generally activates the sympathetic nervous system, increasing heart rate rather than decreasing it as bradycardia would indicate.
B: Constipation is typical during opioid use, not withdrawal. Withdrawal usually causes gastrointestinal hypermotility, leading to diarrhea or cramping, opposite to the slowed bowel movements seen with opioid intake.
C: Hypotension indicates low blood pressure, but opioid withdrawal frequently causes hypertension due to sympathetic overactivity. The body’s compensatory mechanisms elevate blood pressure during withdrawal, making hypotension inconsistent with expected symptoms.
A nurse is caring for a postpartum client who tells the nurse that she does not want any more children. The client asks which birth control method the nurse would recommend. Which of the following responses should the nurse make?
Rationale:
The nurse should respond by saying, "Let's talk about the available options and go from there." This approach respects the client's autonomy and encourages an informed decision tailored to her preferences, medical history, and lifestyle, rather than assuming a one-size-fits-all solution. It fosters open communication and supports shared decision-making for effective postpartum contraceptive planning.
A: "It's your choice, of course, but birth control pills are the most reliable." This statement imposes a specific method prematurely, neglecting individual needs and ignoring that pills may not be the most suitable or preferred option for every postpartum client.
B: "I'd consider an intrauterine device. You won't have to worry about pregnancy." Recommending an IUD without discussion overlooks potential contraindications or personal preferences and fails to involve the client in choosing the method best aligned with her situation.
C: "Your provider usually recommends a diaphragm and spermicidal cream." This suggestion is outdated and less reliable compared to other methods, and it assumes a provider’s preference rather than prioritizing the client’s informed choice and current contraceptive advancements.
A staff nurse reports an observation of a coworker injecting themselves with a syringe in the bathroom. The coworker admits to stealing narcotics from the medication room. The staff nurse should take which of the following courses of action?
Rationale:
The staff nurse should report the incident to the appropriate person in the chain of communication.
Option C is correct because it ensures proper protocol is followed by notifying the designated authority, maintaining patient safety, and addressing the coworker’s illegal behavior responsibly without bypassing institutional policies or compromising ethical standards. This action supports legal requirements and protects the healthcare environment.
A: Report the incident to the other RNs on the shift disperses confidential information inappropriately and lacks formal authority to handle the misconduct effectively.
B: Agree to not report the incident if the coworker seeks treatment neglects patient safety and legal obligations, potentially enabling continued substance abuse and unsafe practices.
D: Agree to not report the incident if the coworker promises to report depends on unreliable assurances, failing to uphold professional accountability and institutional regulations.
A nurse is caring for a client who has sickle cell anemia. The client asks,Why do I feel so tired and fatigued all of the time? Which of the following information should the nurse provide?
Rationale:
You have fewer red blood cells. Sickle cell anemia causes the destruction of red blood cells, leading to anemia. This reduction diminishes oxygen delivery to tissues, causing fatigue and tiredness. The sickled cells have a shorter lifespan, resulting in chronic anemia and insufficient oxygen supply, which explains the client’s persistent tiredness and lack of energy associated with this condition.
A: You have had a gastrointestinal bleed. This option relates to blood loss causing anemia but does not explain fatigue in sickle cell anemia, which primarily results from abnormal red blood cell destruction, not bleeding.
C: You have an autoimmune disease. Sickle cell anemia is a genetic disorder affecting hemoglobin, not an autoimmune condition, making this explanation unrelated to the fatigue experienced.
D: You have a low ferritin level. While low ferritin indicates iron deficiency anemia, sickle cell anemia involves defective hemoglobin and red cell destruction, not primarily iron deficiency causing fatigue.