A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?

"Why do you think your life is not worth it anymore?"

"You can trust me and tell me what you are thinking."

"I need to know what you mean by misery."

"Do you have a plan to end your life?"

Answer and Explanation

The Correct Answer is D

A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.

B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.

C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.

D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.

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Correct Answer is D

Explanation

A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.

B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.

C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.

D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.

A. Take the client to the bathroom to void. B. Ask the client to verify the surgical site. C. Review deep breathing and coughing exercises. D. Raise the side rails on the bed.

Correct Answer is D

Explanation

A. Taking the client to the bathroom after administering a preoperative sedative increases the risk of falls.
B. Surgical site verification should be completed before administering the preoperative medication.
C. Teaching should be done before giving the medication, as the sedative may impair learning and recall.
D. Raising the side rails helps ensure client safety by preventing falls after the medication has been administered.

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A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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