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 C

Explanation

A. Tilted head position facilitates drainage into the nasolacrimal duct, not necessarily into the eye.

B. Washing away exudate is not necessary before administering eye drops.

C. Using aseptic technique to drop medication into the conjunctival sac ensures proper delivery of the medication to the eye.

D. Dropping medication onto the cornea can cause discomfort and may not effectively reach the eye.

A. A client who has chronic obstructive pulmonary disease and needs guidance on incentive spirometry B. A client who had a myocardial infarction 3 days ago and reports chest discomfort C. A client who had a stroke 2 days ago and needs help toileting D. A client who has awoken following a bronchoscopy and requests a drink

Correct Answer is C

Explanation

A. A client with chronic obstructive pulmonary disease who needs guidance on incentive spirometry requires nursing judgment and education to ensure proper technique, so this task is best performed by a nurse.

B. A client who had a myocardial infarction 3 days ago and reports chest discomfort requires assessment and potential intervention by a nurse to address cardiac issues.

C. Assisting a client with toileting typically involves tasks such as transferring, positioning, and providing hygiene assistance, which can be safely delegated to an assistive personnel.

D. Providing a client who has awoken following a bronchoscopy with a drink involves assessing for the absence of nausea or vomiting and ensuring the client can swallow safely, which requires nursing judgment and should be performed by a nurse.

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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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