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 D

Explanation

A. Concerns about returning to school reflect normal adjustment issues and do not indicate immediate danger.

B. Expressing happiness about being home is a positive statement and does not require urgent intervention.

C. Hypervigilance and startle responses are common symptoms of PTSD and should be monitored but are not immediately life-threatening.

D. Expressions of survivor’s guilt or thoughts questioning why one survived while others did not can indicate severe emotional distress and possible risk for self-harm or suicidal ideation. This statement requires immediate assessment and intervention by the nurse.

A. is attempting to obtain attention by manipulating staff. B. has symptoms of alcohol withdrawal delirium. C. may have sustained a head injury before admission. D. is having an acute psychosis.

Correct Answer is B

Explanation

A. The patient’s symptoms are physiological and neurological, not intentional behaviors for attention.

B. Alcohol withdrawal delirium (delirium tremens) typically occurs 48–72 hours after the last drink and includes tremors, agitation, anxiety, diaphoresis, tachycardia, hallucinations, and nightmares—all present in this patient.

C. Although head injury can cause confusion and agitation, the timing of symptoms following alcohol withdrawal aligns more closely with delirium tremens.

D. Acute psychosis can present with hallucinations, but in this case, the onset following alcohol cessation and accompanying autonomic hyperactivity point toward alcohol withdrawal delirium.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is B

Explanation

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