A depressed patient says, "nothing matters anymore." What is the most appropriate response by the nurse?

Try to stay hopeful. Things have a way of working out."

"Are you having thoughts of suicide?"

"Tell me more about what interested you before you became depressed."

"I am not sure I understand what you are trying to say."

Answer and Explanation

The Correct Answer is B

A. Offering platitudes can minimize the patient’s feelings and may shut down further disclosure.
B. Directly asking about suicidal thoughts is the most important and therapeutic response because the statement expresses hopelessness, a major risk factor for suicide. This question assesses immediate safety and guides next steps (ask about intent, plan, means; implement suicide precautions and notify the provider as indicated).
C. Exploring past interests can be therapeutic later, but it does not address the immediate safety concern suggested by the patient’s hopeless statement.
D. Saying you don’t understand is vague and avoids addressing the potential crisis; a direct, nonjudgmental assessment of suicidal ideation is required.

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Correct Answer is A

Explanation

A. The highest priority is monitoring for refeeding syndrome, a potentially fatal complication when nutrition is reintroduced after prolonged starvation. It causes severe electrolyte shifts (especially hypophosphatemia, hypokalemia, and hypomagnesemia) and cardiac/respiratory complications.

B. Important, but not priority. Therapeutic communication builds trust, but physiological safety is the first concern.

C. Help the patient balance energy expenditures with caloric intake. – Useful long-term. This supports recovery but is not immediately life-saving.

D. Assess for depression and anxiety. – Necessary, but secondary. Mental health evaluation is part of holistic care, but immediate physical safety takes precedence.

A. The nurse is viewing the patient's behavior through a cultural filter. B. The patient is giving positive feedback about the nurse's communication techniques. C. The patient is demonstrating psychotic behaviors. D. The patient's verbal and nonverbal messages are incongruent.

Correct Answer is D

Explanation

A. There is no indication that cultural bias is affecting interpretation; the focus is on the mismatch between verbal and nonverbal cues.

B. While the patient says they enjoy the interaction, their nonverbal behavior (fidgeting, covering face, looking under chair) suggests discomfort or anxiety, not purely positive feedback.

C. The behaviors described (fidgeting, covering face) do not indicate hallucinations or delusions typical of psychosis.

D. The patient verbally states enjoyment, but their body language suggests discomfort, anxiety, or internal conflict, indicating incongruence between words and actions.

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A depressed patient says, "nothing matters anymore." What is the most appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which nursing intervention has the highest priority for a patient who is diagnosed with anorexia nervosa and has begun to gain weight?

Correct Answer is A

Explanation

Documentation in a patient's chart shows. "Throughout a 5-minute interaction, patient fidgeted and tapped their left foot, periodically covered their face with their hands, and looked under chair while stating, 1 enjoy spending time with you." Which analysis is most accurate?

Correct Answer is D

Explanation

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