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. "Why do you think your life is not worth it anymore?": Asking “why” can feel judgmental and may cause the client to withdraw rather than share openly. It directs the conversation toward justification rather than safety assessment, delaying the nurse’s responsibility to determine immediate suicide risk.
B. "You can trust me and tell me what you are thinking": While supportive, this statement is too vague and does not address the urgent need to assess suicidal intent. It does not guide the client toward providing specific information needed to evaluate the level of risk and plan for safety.
C. "I need to know what you mean by misery": This response explores the client’s feelings but does not directly address the expressed suicidal thoughts. Focusing on the term “misery” may allow critical details about planning or intent to go unassessed during a potentially dangerous moment.
D. “Do you have a plan to end your life?”: This is an appropriate and essential safety-focused response because it directly assesses the client’s level of suicidal intent and the presence of a plan. Determining whether a plan exists helps the nurse evaluate the immediacy of the risk and initiate protective interventions without delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. An air leak noted at the insertion site: An air leak can cause continuous bubbling in the water seal chamber, but it does not prevent tidaling. Tidaling reflects intrathoracic pressure changes with respiration, so an air leak alone does not explain the absence of tidaling.
B. The tubing may be kinked: Tidaling stops when there is an obstruction in the chest tube system, such as a kinked or clamped tube. This prevents the normal movement of fluid in the water seal chamber that corresponds with the client’s respiratory cycle, making it the most likely cause of absent tidaling.
C. Water needs to be added to the suction-control chamber: Low water in the suction-control chamber affects the amount of suction delivered, not tidaling in the water seal chamber. The water seal chamber relies on the client’s respiration to show fluctuations, so adding water to suction does not restore tidaling.
D. The suction is set too low: Suction settings influence the rate of fluid evacuation and bubbling, but they do not control tidaling. Absence of tidaling usually indicates a mechanical obstruction rather than a suction problem.
Correct Answer is A
Explanation
A. "I don't hear the voices. Concentrate on my voice instead.": This response validates the client’s experience without reinforcing the hallucination and redirects attention to reality. It helps the client focus on the present environment and encourages engagement in reality-based interactions, which is a therapeutic approach for managing auditory hallucinations.
B. "They cannot hurt you. Don't be afraid of what they say.": While intended to reassure, this response may be dismissive of the client’s experience and can increase anxiety or mistrust. It does not provide a practical strategy for coping with the hallucinations.
C. "Let's go to a quiet room where the voices won't follow.": Hallucinations are internally generated and are not affected by the external environment. Moving to a quiet room may not decrease the hallucinations and can inadvertently reinforce the belief in their reality.
D. "The voices are not real, and you need to get to group.": Telling the client the voices are not real can invalidate their experience and reduce therapeutic rapport. Forcing participation in activities without addressing the hallucinations can increase stress and noncompliance.
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