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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Schedule regular weigh-in times: Monitoring the client's weight on a regular schedule is important in managing anorexia nervosa. It helps track progress and any potential complications related to weight loss.

B. Allow the client to eat at any time: For individuals with anorexia nervosa, there is typically a structured meal plan that is carefully monitored by healthcare professionals. Allowing the client to eat at any time might disrupt the planned nutritional intake.

C. Provide privacy when friends visit: Privacy is important, but it should be balanced with ensuring the client's safety and adherence to the treatment plan. Visitors might need to be supervised to prevent any behaviors that could exacerbate the disorder.

D. Compliment the client for weight gain: While support and encouragement are important, complimenting a client for weight gain might inadvertently reinforce a focus on body image and reinforce disordered eating behavior. It's crucial to provide positive reinforcement for adherence to the treatment plan and progress in recovery, rather than emphasizing weight changes.

A. The partner has placed locks at the top of the doors leading to the outside. B. The partner has hired a house cleaner. C. The partner has lost 20 lb in the past 2 months. D. The partner redirects the client when the client is frustrated.

Correct Answer is C

Explanation

A. The partner has placed locks at the top of the doors leading to the outside:

Explanation: Placing locks at the top of doors leading outside is a safety measure to prevent the person with Alzheimer's disease from wandering or getting lost. While this does show that the partner is taking proactive steps to ensure the client's safety, it is not necessarily indicative of caregiver role strain.

B. The partner has hired a house cleaner:

Explanation: Hiring a house cleaner can be a sign of caregiver role strain. Caregivers often become overwhelmed with the responsibilities of caring for a person with Alzheimer's disease, and hiring help for household tasks can be an indication that they are finding it challenging to manage everything on their own.

C. The partner has lost 20 lb in the past 2 months:

Explanation: Rapid weight loss can be a sign of caregiver stress or burnout. The emotional and physical demands of caring for a loved one with Alzheimer's disease can lead to neglect of one's own well-being, including proper nutrition and self-care.

D. The partner redirects the client when the client is frustrated:

Explanation: While redirecting the client when they're frustrated shows that the partner is using appropriate strategies to manage challenging behaviors associated with Alzheimer's disease, this observation doesn't necessarily indicate caregiver role strain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who has anorexia nervosa. Which of the following nursing interventions should the nurse take?

Correct Answer is A

Explanation

A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?

Correct Answer is C

Explanation

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