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 C
Explanation
Choice A Reason:
Elevated blood pressure and heart rate are not typically indicative of sedative-hypnotic drug use. These symptoms are more commonly associated with stimulant use or withdrawal from depressants.
Choice B Reason:
Increased energy and hyperactivity are also not indicative of sedative-hypnotic drug use. These are symptoms that might be observed with stimulant drugs or during withdrawal from depressants.
Choice C Reason:
Excessive drowsiness and sedation are hallmark signs of sedative-hypnotic drug use. Sedative-hypnotics, which include drugs like benzodiazepines and barbiturates, work by depressing the central nervous system, leading to a decrease in brain activity and causing drowsiness and sedation.
Choice D Reason:
While improved sleep quality and duration might be an intended effect of sedative-hypnotic drugs, they are not indicative of acute use or intoxication. These drugs are often prescribed to help with sleep; however, their misuse can lead to excessive sedation beyond normal sleep patterns.
Correct Answer is B
Explanation
Choice A: I will join a book club in my neighborhood.
Joining a book club in the neighborhood can be a good step towards socializing and overcoming the fear of open or crowded places. However, the success of this step largely depends on the severity of the client's agoraphobia.
Choice B: I plan to sit on a park bench for a few minutes each day.
This is a good practice as it involves gradual exposure to the outside world, which can help in managing agoraphobia. The client can start with a few minutes and then gradually increase the time spent outside.
Choice C: I should avoid entering elevators and other closed spaces.
Avoidance is not a solution for agoraphobia. In fact, avoiding places or situations out of fear can reinforce the phobia. The goal of treatment is to help the client face these situations rather than avoid them.
Choice D: I can try participating in group therapy every week.
Group therapy can be beneficial as it provides a supportive environment where the client can learn from the experiences of others dealing with the same issues. It can also help the client feel less isolated.
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