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
Choice A reason: Asking why the client thinks their life is not worth it is too broad and may come across as challenging or judgmental. It does not directly assess the client’s risk of harm and may not provide the nurse with the critical information needed to ensure safety.
Choice B reason: Telling the client they can trust the nurse is supportive, but it is vague and does not directly address the immediate risk of suicide. While building trust is important, the priority is to assess the client’s intent and plan.
Choice C reason: Asking what the client means by misery explores feelings but does not assess the immediate risk of suicide. While understanding the client’s emotional state is valuable, the nurse must first determine if the client has a plan, which indicates the level of risk.
Choice D reason: Asking if the client has a plan to end their life is the most appropriate response because it directly assesses suicide risk. The presence of a plan indicates a higher level of danger and guides the nurse in determining the urgency of interventions. This is the correct answer because it prioritizes safety and risk assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Reporting suspected abuse to Adult Protective Services is the nurse’s legal and ethical responsibility. Visible contusions on all extremities raise concern for physical abuse, and mandatory reporting laws require healthcare providers to notify protective services to ensure client safety. This is the correct action.
Choice B reason: Interviewing the client with the adult child present is inappropriate because it may prevent the client from speaking honestly about the situation. The presence of a potential abuser can inhibit disclosure and compromise assessment accuracy.
Choice C reason: Telling the client they must answer every Question is coercive and violates patient autonomy. Clients have the right to refuse to answer questions, and forcing responses is non-therapeutic.
Choice D reason: Advising the client to consult a social worker is supportive but insufficient. While social workers provide resources and counseling, the priority action is mandatory reporting to ensure immediate safety.
Correct Answer is C
Explanation
Choice A reason: Arterial blood gases are not routinely required before initiating lithium therapy. They are more relevant in respiratory or metabolic disorders, not in baseline monitoring for lithium.
Choice B reason: Total cholesterol is not directly affected by lithium therapy. While metabolic monitoring may be necessary for some psychiatric medications, cholesterol is not a priority baseline test for lithium.
Choice C reason: Thyroid hormones should be evaluated because lithium can interfere with thyroid function, leading to hypothyroidism. Baseline thyroid levels are essential to monitor for potential adverse effects during therapy.
Choice D reason: Hemoglobin levels are not directly impacted by lithium therapy. While general health screening may include hemoglobin, it is not a priority baseline test specific to lithium administration.
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