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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Neurological assessment is important, but not the priority since opioid overdose primarily causes life-threatening respiratory depression.
B. Respiratory assessment is the highest priority because opioids suppress the respiratory center, leading to hypoventilation, hypoxia, or apnea.
C. Hepatic assessment is not the immediate concern in acute overdose.
D. Cardiovascular assessment is necessary, but respiratory status takes precedence because airway and breathing are life-sustaining priorities.
Correct Answer is B
Explanation
A. While laboratory tests are important for assessing electrolyte imbalances and liver function, they are not the immediate priority in acute alcohol withdrawal.
B. Acute alcohol withdrawal can rapidly lead to seizures and delirium tremens, which are life-threatening. Patient safety and prevention of injury are the priority.
C. Neurological assessment is important, but first ensuring the client’s safety from potential seizures takes precedence.
D. IV access is necessary for fluid or medication administration, but it follows implementing immediate safety measures.
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