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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Echolalia, or repeating the words of others, can be a manifestation of schizophrenia.
B. Word salad, or a jumble of incoherent words and phrases, can occur in schizophrenia.
C. Expressing interest in ADLs is not typically associated with schizophrenia and may indicate a different mental health state.
D. A blunt affect, or reduced emotional expression, is a common symptom of schizophrenia.
E. Delusions, or fixed false beliefs, are a hallmark symptom of schizophrenia.
Correct Answer is C
Explanation
A. Performing another internal exam is not the priority at this moment. The priority is assessing fetal well-being.
B. Notifying the client's provider may be necessary, but it is not the immediate priority.
C. Checking the fetal heart rate (FHR) is the priority action to assess fetal well-being after the observed fluid gush, as it could indicate rupture of membranes and potentially fetal distress.
D. Obtaining a pH test of the fluid can be done later for confirmation of rupture of membranes but is not the immediate priority compared to assessing fetal well-being.
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