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?"

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A: "I can't call a doctor in the middle of the night unless it's an emergency."
This response may seem reasonable, but it could escalate the situation if the client feels their concerns are not being taken seriously. It's important to validate the client's feelings and find a solution that respects both their needs and the realities of the situation.

Choice B: "You must be very upset about something."
This response validates the client's feelings and opens up a dialogue. It shows empathy and understanding, which can help de-escalate the situation.

Choice C: "Go back to your room, and I'll try to get in touch with your doctor."
This response acknowledges the client's request and provides a clear action plan. However, it's important to follow through on this promise to maintain trust.

Choice D: "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and likely to escalate the situation. It's important to remain calm and professional, even when dealing with difficult behavior.

A. The client is seeking sympathy and pity from healthcare providers by feigning illness or injury. B. The client is seeking attention and validation through inducing injury or illness. C. The client's symptoms are the result of a misdiagnosis or medical error. D. The client is seeking financial gain through feigning illness or injury. E. The client is experiencing physical symptoms related to an underlying medical condition.

Correct Answer is ["A","B"]

Explanation

Choice A reason:

This hypothesis aligns with the typical motivations seen in factitious disorder, where individuals intentionally produce or exaggerate symptoms of illness in themselves to receive attention, sympathy, and care from medical personnel¹. The nurse should prioritize understanding this behavior to manage the client's care effectively and to avoid unnecessary medical interventions.

Choice B reason:

Similar to choice A, individuals with factitious disorder may induce injury or illness to fulfill a psychological need for attention and validation. Recognizing this motivation is crucial for the nurse to provide appropriate psychological support and to prevent further self-harm.

Choice C reason:

While misdiagnosis or medical error can occur, this is not typically a hypothesis that should be prioritized in the care of a client with factitious disorder. The disorder involves intentional actions by the client, not errors by healthcare providers.

Choice D reason:

Seeking financial gain is more characteristic of malingering than factitious disorder. In factitious disorder, the primary motivation is psychological gratification from playing the patient role, rather than external incentives like financial gain.

Choice E reason:

Factitious disorder involves the intentional production of symptoms without an underlying medical condition. Therefore, this hypothesis would not be a priority in the care of a client with factitious disorder, as the symptoms are not related to a genuine medical condition but are self-induced.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse who works in a psychiatric unit is caring for a client diagnosed with bipolar disorder. The client comes to the nurse's station at 0300, demanding that the nurse call the provider immediately. Which of the following responses should be an appropriate response by the nurse?

Correct Answer is B

Explanation

A client presents with symptoms consistent with factitious disorder. Which of the following hypotheses should the nurse prioritize in the care of this client? (Select all that apply)

Correct Answer is ["A","B"]

Explanation

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