A client states, "My life has no meaning right now." Which of the following responses should the nurse make?
Have you been thinking about harming yourself?
How long have you been feeling this way?
Tell me what is going on with you right now.
Do you really think your life has no purpose?
The Correct Answer is C
Choice A reason: Asking the client if they have been thinking about harming themselves is not the best response, as it may sound accusatory or judgmental. It may also make the client defensive or reluctant to share their feelings. The nurse should assess the client's suicide risk later, after establishing rapport and trust.
Choice B reason: Asking the client how long they have been feeling this way is not the most appropriate response, as it may imply that the nurse is more interested in the duration of the problem than the client's current situation. It may also suggest that the nurse expects the client to have a clear timeline of their feelings, which may not be the case.
Choice C reason: Telling the client to share what is going on with them right now is the best response, as it shows empathy and genuine interest in the client's perspective. It also invites the client to express their thoughts and emotions, and helps the nurse identify the factors that contribute to the client's sense of meaninglessness.
Choice D reason: Asking the client if they really think their life has no purpose is not a helpful response, as it may sound dismissive or sarcastic. It may also make the client feel invalidated or misunderstood, and reinforce their negative beliefs. The nurse should avoid challenging the client's statements, and instead explore the reasons behind them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
Correct Answer is D
Explanation
Choice A reason: Oliguria is not a condition that a nurse should expect in a client who has hypoglycemia. Oliguria is a reduced urine output, typically defined as less than 0.5 ml/kg/hour in an adult³. Oliguria can be a sign of dehydration, kidney failure, or urinary obstruction, but it is not related to low blood sugar levels.
Choice B reason: Diplopia is not a condition that a nurse should expect in a client who has hypoglycemia. Diplopia is a double vision, or seeing two images of a single object. Diplopia can be caused by various eye problems, such as strabismus, cataracts, or nerve damage, but it is not a common symptom of low blood sugar levels.
Choice C reason: Hypoglycemia is not a condition that a nurse should expect in a client who has hypoglycemia. Hypoglycemia is the condition itself, not a symptom. Hypoglycemia is a low blood sugar level, usually below 70 mg/dl. Hypoglycemia can result from taking too much insulin or other diabetes medications, skipping or delaying meals, exercising more than usual, or drinking alcohol.
Choice D reason: Dizziness is a condition that a nurse should expect in a client who has hypoglycemia. Dizziness is a feeling of lightheadedness, faintness, or unsteadiness. Dizziness can occur when the brain does not receive enough glucose, which is its main energy source. Dizziness can also be accompanied by other symptoms of hypoglycemia, such as confusion, hunger, sweating, shakiness, or weakness.
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