A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

"Perhaps you should discuss this with your physician."

"Of course, you aren't going to die, at least not in the immediate future."

"I recommend you exercise daily and avoid smoking to decrease your risk."

"Tell me more about these fears of dying from a heart attack.".

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Deflecting the client's concerns to the physician dismisses the client's immediate need for emotional support and therapeutic communication.

It can hinder the development of a trusting nurse-client relationship.

The nurse is responsible for addressing the client's psychosocial needs, not solely deferring them to other healthcare professionals.

Choice B rationale:

Offering false reassurance is inappropriate and potentially harmful. It can erode trust if the client's fears are later realized.

It minimizes the client's legitimate concerns and invalidates their emotional experience.

Choice C rationale:

While lifestyle modifications are essential for managing coronary artery disease, providing unsolicited advice at this moment disregards the client's emotional distress.

It prioritizes physical health over the client's psychological well-being. It can be perceived as dismissive of the client's fears and concerns.

Choice D rationale:

Inviting the client to elaborate on their fears demonstrates active listening and encourages therapeutic communication. It validates the client's concerns and shows empathy for their emotional experience.

It provides an opportunity to assess the client's understanding of their condition and identify specific fears or misconceptions. It establishes a foundation for exploring coping mechanisms and providing appropriate support and education.

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Correct Answer is C

Explanation

The correct answer(s) is/are:

C. Telling his parents that he doesn't want to talk about the suicide attempt.

Rationale:

Choice A: Planning to give his Xbox console to his best friend.

While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.

Choice B: Stating that he wants to be with his peers more than with his parents.

This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.

Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:

Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.

Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.

Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.

Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.

Choice D: Preferring to eat his meals while watching TV.

This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.

Conclusion:

Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.

A. Instruct the client on relaxation techniques for use when anxiety level increases. B. Discuss many alternative coping strategies with the client. C. Identify precipitating factors for ritualistic behaviors. D. Provide a highly structured activity schedule for the client.

Correct Answer is C

Explanation

Choice A rationale: Instructing the client on relaxation techniques for use when anxiety level increases is a beneficial intervention for a client with OCD. However, it is not the first action the nurse should take. The nurse needs to understand the client’s condition, including the triggers for their ritualistic behaviors, before they can effectively guide the client in managing their anxiety.

Choice B rationale: Discussing many alternative coping strategies with the client is an important part of OCD management. However, this should come after understanding the client’s condition and the triggers for their ritualistic behaviors. Without this understanding, the coping strategies suggested may not be effective or relevant.

Choice C rationale: Identifying precipitating factors for ritualistic behaviors is the first action the nurse should take. Understanding what triggers the client’s OCD behaviors is crucial in developing an effective care plan. This understanding allows the nurse to work with the client to develop strategies to manage their triggers and reduce the frequency and intensity of their OCD behaviors.

Choice D rationale: Providing a highly structured activity schedule for the client can be helpful in managing OCD. However, this should not be the first action. The nurse needs to first understand the client’s condition, including the triggers for their ritualistic behaviors. This understanding will allow the nurse to develop a schedule that takes into account the client’s triggers and incorporates effective coping strategies.

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A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

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Explanation

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Explanation

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