A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?
"Do you really think your family would be better off without you?"
"Tell me what is happening right now."
"When did you first start feeling this way?"
"Are you thinking of harming yourself?"
The Correct Answer is D
Choice A reason:
Asking the client if they really think their family would be better off without them could potentially validate the client's feelings of worthlessness and is not a priority when immediate safety concerns are present.
Choice B reason:
While it's important to understand the client's current situation, this open-ended question may not directly address the risk of harm the client might pose to themselves. It should follow after ensuring the client's safety.
Choice C reason:
Inquiring about the onset of these feelings is part of a thorough assessment but is not the most immediate concern when a client expresses thoughts that may indicate a risk of self-harm.
Choice D reason:
This direct question addresses the immediate safety concern and is the priority response when a client indicates they may be a danger to themselves. It is essential to assess for suicidal ideation directly to take appropriate steps to ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Caffeine is not typically associated with liver cirrhosis. While excessive consumption of caffeine can have various health implications, it is not considered a direct cause of liver cirrhosis. The liver metabolizes caffeine without significant damage or scarring to the liver tissue.
Choice B reason:
Alcohol is the primary cause of liver cirrhosis in many cases. Chronic alcohol abuse leads to liver damage and subsequent scarring, known as cirrhosis. The liver's function is to process and filter toxins, including alcohol. Excessive and prolonged alcohol consumption overwhelms the liver's ability to process it, leading to inflammation, damage, and eventually scarring of the liver tissue.
Choice C reason:
Inhalants are substances that produce chemical vapors that can be inhaled to induce a psychoactive, or mind-altering, effect. While they can cause a range of acute and chronic health issues, including damage to the heart, kidneys, lungs, and brain, they are not commonly associated with liver cirrhosis. Liver cirrhosis is not a typical consequence of inhalant use.
Choice D reason:
Cocaine use can lead to various health problems, including cardiovascular and neurological issues, but it is not commonly identified as a primary cause of liver cirrhosis. Cocaine metabolites can be toxic to the liver; however, the direct causation of cirrhosis from cocaine alone is less established compared to alcohol-related liver disease.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Reason:
Aspiration is a significant risk for clients with acute alcohol intoxication due to an impaired gag reflex. Alcohol can depress the central nervous system, leading to a decreased level of consciousness and a diminished gag reflex, which increases the risk of aspiration of gastric contents into the lungs.
Choice B Reason:
Impaired coordination and judgment are common in acute alcohol intoxication, increasing the risk of injury. Alcohol affects the cerebellum, the part of the brain that regulates coordination and balance, as well as the frontal lobes, which are responsible for judgment and decision-making.
Choice C Reason:
Alcohol is metabolized by the liver, and excessive alcohol intake can lead to alcohol toxicity and liver impairment. Acute alcohol intoxication can cause hepatic steatosis, alcoholic hepatitis, and even acute liver failure in severe cases.
Choice D Reason:
Dizziness and an unsteady gait are direct effects of alcohol's impact on the vestibular system and the brain's ability to process spatial information, leading to an increased risk of falls.
Choice E Reason:
Alcohol intoxication can impair immune function, making the client more susceptible to infections. Alcohol disrupts immune pathways in complex ways, which can impair the body's ability to defend against infections
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