A client who has major depressive disorder states to 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?
"Are you thinking of harming yourself?"
"Do you really think your family would be better off without you?"
"When did you first start feeling this way?"
"Tell me what is happening right now."
The Correct Answer is A
A. "Are you thinking of harming yourself?": Correct
This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.
B. "Do you really think your family would be better off without you?": Incorrect
While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.
C. "When did you first start feeling this way?": Incorrect
While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.
D. "Tell me what is happening right now.": Incorrect
This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route."
This response is directive and dismissive of the client's choice. It does not promote open communication or respect for the client's autonomy and beliefs.
B. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you."
While healthcare providers have expertise, this response doesn't address the client's concerns or give them an opportunity to express their feelings. It may come across as authoritarian and not respecting the client's wishes.
C. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice."
This response uses scare tactics and doesn't address the client's individual needs or concerns. It does not foster a trusting and respectful nurse-client relationship.
D. "Tell me more about your concerns about taking chemotherapy."
This is the most appropriate response. It demonstrates active listening, empathy, and a willingness to understand the client's perspective. By asking the client to share more about their concerns, the nurse can engage in a meaningful conversation and provide information and support based on the client's needs.
Correct Answer is B
Explanation
A. A client exhibiting psychotic behavior
Group therapy is generally not recommended for clients who are actively exhibiting psychotic behavior. Psychotic behavior can include hallucinations, delusions, and severe thought disturbances, which might impede the individual's ability to effectively participate and benefit from group therapy. Such clients often require more immediate and individualized attention to address their acute symptoms.
B. A client who has been taking amitriptyline for 3 months for depression
This is the correct choice. A client who has been taking amitriptyline for 3 months for depression is likely to have their symptoms more stabilized and under better control compared to acute situations. They might be at a stage where they can engage in group therapy to discuss their experiences, coping strategies, and learn from others in a similar situation.
C. A client who is experiencing alcohol intoxication
Group therapy is not appropriate for clients who are currently intoxicated, as their ability to actively participate and engage in therapeutic discussions may be compromised. Addressing the effects of alcohol intoxication and ensuring the client's safety would be a priority before considering group therapy.
D. A client admitted 12 hours ago for acute mania
Clients admitted for acute mania often require stabilization and intervention to manage their manic symptoms. In the early stages of admission, they might not be in a state conducive to group therapy. Once their acute symptoms are better controlled and they have had time to stabilize, they could potentially benefit from group therapy as part of their overall treatment plan.
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