A mental health nurse is caring for a client who recently attempted to self-harm. The client states, "I wish I were dead." Which of the following responses should the nurse make?

"You seem like you're feeling hopeless."

"Suicide is not the answer to your problems."

"Did you take your medications today?"

"Don't worry. Everything will be just fine."

Answer and Explanation

The Correct Answer is A

A. "You seem like you're feeling hopeless.": This response acknowledges the client’s emotional state and invites further discussion, which is essential in managing suicidal ideation. It validates the client’s feelings while opening a therapeutic dialogue that helps the nurse assess risk, provide support, and ensure safety.

B. "Suicide is not the answer to your problems.": This response can feel dismissive and may shut down communication. It offers a directive rather than exploring the client’s feelings, which may increase the client’s sense of isolation. Effective therapeutic communication focuses on understanding before offering guidance.

C. "Did you take your medications today?": Asking about medication adherence shifts the focus away from the client's emotional distress. While medication compliance is important, it does not address the immediate expression of suicidal thoughts or support emotional exploration.

D. "Don't worry. Everything will be just fine.": Offering false reassurance minimizes the client's feelings and can worsen distress. It closes communication and prevents the nurse from gathering important information about the client’s level of suicidal risk, which is critical in this situation.

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Correct Answer is B

Explanation

A. Position the client in a lithotomy position during the epidural procedure: Epidurals are typically administered with the client in a sitting position or lying on their side with the back arched (fetal position) to allow access to the lumbar spine. Lithotomy position is not used for epidural placement.

B. Monitor the client's bladder for distention: Epidural anesthesia can decrease bladder sensation and the ability to void, increasing the risk of urinary retention. Monitoring for bladder distention and assisting with catheterization if needed is an essential nursing action to prevent complications.

C. Administer oxygen to the client at 2 L/min via face mask: Oxygen is not routinely administered to clients receiving an epidural unless there is evidence of maternal hypoxia or fetal distress. Routine oxygen is not required and should be based on assessment findings.

D. Limit turning the client during labor: While care must be taken to maintain the epidural catheter, clients can still be repositioned to promote comfort and labor progression. Turning is not prohibited, but care should be taken to avoid dislodging the catheter.

A. "I should lie down after my meals." B. "I should avoid eating hot foods." C. "I should drink a caffeinated beverage one hour before a meal." D. "I should increase my intake of liquids with meals."

Correct Answer is B

Explanation

A. "I should lie down after my meals.": Lying down immediately after eating can worsen nausea and increase the risk of acid reflux. Clients should remain upright after meals to facilitate digestion and reduce nausea.

B. "I should avoid eating hot foods.": Avoiding hot, spicy, or strong-smelling foods can help reduce nausea and gastrointestinal discomfort. Eating bland, cool, or room-temperature foods is easier on the stomach and aligns with dietary recommendations for gastroenteritis.

C. "I should drink a caffeinated beverage one hour before a meal.": Caffeine can irritate the gastrointestinal tract and worsen nausea. Clients should avoid caffeinated beverages during episodes of gastroenteritis to prevent exacerbation of symptoms.

D. "I should increase my intake of liquids with meals.": Drinking large amounts of liquid with meals can contribute to feelings of fullness, bloating, and nausea. It is generally recommended to sip fluids between meals rather than during meals to maintain hydration without worsening symptoms.

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A mental health nurse is caring for a client who recently attempted to self-harm. The client states, "I wish I were dead." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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