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: Isolate the client for a period of time.
Isolation can lead to increased anxiety and may not be beneficial for a client with OCD. It does not address the underlying issue of the compulsive behaviors and may even exacerbate them.

Choice B: Plan the client's schedule to allow time for rituals.
This is generally the most effective approach. By allowing time for rituals, the nurse acknowledges the client's need for these behaviors and reduces anxiety. Over time, the goal would be to gradually reduce the time spent on these rituals as the client develops more effective coping strategies.

Choice C: Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.
While it's important to have a structured environment, setting strict limits on compulsive behaviors can increase anxiety and resistance. It's more beneficial to work with the client to gradually decrease these behaviors rather than attempting to stop them abruptly.

Choice D: Confront the client about the senseless nature of the repetitive behaviors.
Confrontation is not typically helpful for clients with OCD. These clients are usually well aware that their behaviors are irrational, but they feel compelled to perform them anyway. Confrontation can lead to increased anxiety and defensiveness.

A. "The unit rules state that you may not remain in bed." B. "You can remain in bed until you feel well enough to join the group." C. "I will assist you in getting out of bed and getting dressed." D. "If you don't participate in your care, you will not get better."

Correct Answer is C

Explanation

Choice A reason:
This choice represents an authoritative approach, which may not be effective with a depressed client who is refusing therapy and ADLs. It does not offer support or understanding of the client's condition and may exacerbate feelings of helplessness or resistance to care.

Choice B reason:
While this statement offers a degree of autonomy to the client, it lacks the active encouragement and assistance that might be necessary to motivate a client who is depressed. It does not address the importance of participating in therapy or ADLs for the client's recovery.

Choice C reason:
This is the most therapeutic choice as it offers both support and a gentle nudge towards participation. It acknowledges the client's current state and provides a clear, immediate, and supportive next step. This approach can help reduce the client's feelings of being overwhelmed and can foster a sense of collaboration between the nurse and the client.

Choice D reason:
This statement, although factual, may come across as confrontational and could potentially discourage the client further. It does not provide the supportive framework that is crucial for engaging a client who is struggling with depression.

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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 in a mental health facility is planning care for a client who has obsessive-compulsive disorder (OCD) and is newly admitted to the unit. Which of the following actions should the nurse plan to take regarding the client's compulsive behaviors?

Correct Answer is B

Explanation

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?

Correct Answer is C

Explanation

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