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 D

Explanation

A. "It doesn't really matter what time you take your medications as long as you don't skip any doses."

While it's important not to skip doses, taking medications at specific intervals is often necessary for maintaining therapeutic blood levels and optimal treatment outcomes. Disregarding specific timing can affect the effectiveness of the medications.

B. "We'll have to talk to your provider about switching to an alternative schedule."

This response may not consider the client's preferences and might not be necessary if the client's current schedule can be adjusted to suit their routine. Collaboration between the nurse and the client is essential.

C. "You really shouldn't change the schedule we established here in the facility."

While continuity in medication schedules is important, if the established schedule doesn't align with the client's daily life, there should be flexibility to adjust it in a way that still maintains the effectiveness of the medications.

D. "Let's work together to devise a time schedule that is convenient for you on a daily basis."

Explanation: It's important to consider the client's lifestyle and routines when developing a medication schedule to ensure optimal adherence. Collaboratively working with the client to create a schedule that fits their daily activities increases the likelihood that they will consistently take their medications as prescribed.

A. "How long has this been going on?" B. "Why do you think you are so anxious?" C. "Have you talked to your parents about this yet?" D. "It sounds like you're having a difficult time."

Correct Answer is D

Explanation

A. "How long has this been going on?":

While this question is important for gathering more information, it may come across as more investigative or less empathetic at this initial stage of the conversation.

B. "Why do you think you are so anxious?":

While it's important to understand the client's perspective, this response might come across as confrontational or judgmental. It's better to create an open and non-judgmental environment for the client to share their feelings.

C. "Have you talked to your parents about this yet?":

This response assumes that the client has parents to talk to and may not be relevant for all clients. It's also important to establish trust and rapport with the client before asking about their support network.

D. "It sounds like you're having a difficult time.":

This response is empathetic and validating. It acknowledges the client's feelings without making assumptions or demands, creating a supportive environment for further discussion.

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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?

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