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 B
Explanation
Choice A reason: The test does not monitor the progression of the disease, as it only detects the presence of antibodies to HIV, not the amount of virus or the damage to the immune system. Other tests, such as viral load and CD4 count, are used to monitor the progression of HIV infection and the response to treatment.
Choice B reason: The test measures antibodies to the virus, which are produced by the immune system in response to HIV infection. The test is used to screen for HIV infection and to confirm the diagnosis. A positive result indicates that the person has been exposed to HIV and has developed antibodies to the virus.
Choice C reason: The test results are not accurate 24 hours after exposure to the virus, as it takes time for the body to produce enough antibodies to be detected by the test. The window period, which is the time between exposure to HIV and a positive test result, varies from person to person, but it can range from 3 weeks to 3 months. Therefore, a negative result does not necessarily rule out HIV infection, and a repeat test may be needed after the window period.
Choice D reason: A positive result does not require initiating immunoglobulin administration, as immunoglobulin is not a treatment for HIV infection. Immunoglobulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not affect HIV. A positive result requires further confirmation by a more specific test, such as the Western blot, and referral to a specialist for treatment and counseling.
Correct Answer is C
Explanation
Choice A reason: Alerting the family members of coworkers about possible exposure to anthrax is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The family members of coworkers are not at risk of infection, and alerting them may cause unnecessary panic and stigma.
Choice B reason: Placing the employee under quarantine for 14 days is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to be isolated from others, and quarantine may interfere with their access to medical care and social support.
Choice C reason: Referring coworkers who might have been exposed to a provider for prophylactic antibiotics is an action that the nurse should take. Anthrax is a serious bacterial infection that can be fatal if left untreated. The coworkers who might have been exposed to the same source of anthrax as the employee should receive prophylactic antibiotics as soon as possible to prevent the infection from developing.
Choice D reason: Instructing the employee to wear a mask at work is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to wear a mask at work, and doing so may cause unnecessary discomfort and discrimination.
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