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 C

Explanation

Choice A reason:
Complicated grieving is a natural response to the loss of a loved one, characterized by intense sorrow and longing. However, the client's statement indicates a sense of hopelessness and a lack of desire to continue living, which goes beyond the typical symptoms of complicated grieving. While it is important to assess for complicated grieving, the client's expression of not wanting to go on suggests a more immediate risk.

Choice B reason:
Chronic pain can lead to depression and decreased quality of life, but the client does not mention any physical pain. The absence of such complaints makes chronic pain a less likely cause for the client's current state. It is still important to assess for any physical discomfort that the client may not be communicating.

Choice C reason:
The client's statement of questioning the purpose of continuing life is a clear indicator of suicidal ideation, which warrants immediate further assessment. The risk for suicide is often heightened following significant life events such as the loss of a spouse. The nurse must prioritize this assessment to ensure the client's safety.

Choice D reason:
Social isolation can contribute to feelings of loneliness and depression, particularly in the elderly who have lost a significant other. While social isolation is a concern and can exacerbate other mental health issues, the client's explicit questioning of life's worth points more directly to a risk for suicide.

A. "I check any room I enter because the enemy is still after me and could be hiding anywhere." B. "My child was born with a birth defect due to an exposure I had overseas." C. "I killed four enemy soldiers with my bare hands and saved my entire battalion." D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Correct Answer is D

Explanation

Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.

Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.

Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.

Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.

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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

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Correct Answer is C

Explanation

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Explanation

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