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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Rationale:
• Encourage the client to avoid napping during the day: A manic client has a severely diminished drive for sleep and is at risk for physical exhaustion. Any opportunity for rest or sleep, even a brief nap, should be encouraged to protect the client's physiological health.
• Minimize environmental stimuli for the client: Manic clients are highly distractible and easily overstimulated. Reducing noise, dimming lights, and providing a private room helps decrease the "manic energy" and promotes safety and calm.
• Provide the client with high-calorie fluids every hr: The client has not eaten for an extended period and exhibits poor recall of the last meal, indicating risk of malnutrition. High-calorie fluids are an appropriate intervention to ensure adequate caloric intake and hydration, thus supporting metabolic needs during the maniac episodes.
• Weigh the client each day: Daily weight monitoring helps track nutritional status and detect early signs of fluid imbalance or rapid weight loss, which can occur in clients with poor intake or hyperactivity during mania. It also assists in evaluating effectiveness of nutritional interventions. This practice provides objective data to guide care planning and assess health risks associated with inadequate intake.
Correct Answer is B
Explanation
A. "You should massage one of your nipples to stimulate contractions of your uterus.": Nipple stimulation is used to induce contractions during a contraction stress test, not a nonstress test. For a nonstress test, the goal is to assess fetal heart rate in response to fetal movements without inducing contractions.
B. "You will have a Doppler transducer applied to your abdomen during the test.": A nonstress test involves placing a Doppler transducer on the maternal abdomen to monitor fetal heart rate and a tocodynamometer to detect uterine activity. The test is noninvasive and monitors fetal heart rate accelerations in response to movement.
C. "You should avoid eating or drinking for 4 hours before the test.": Fasting is not required for a nonstress test. In fact, some providers encourage eating beforehand to promote fetal activity, which helps obtain accurate heart rate accelerations.
D. "You will need blood work before and after the test.": Blood work is not required for a nonstress test. The test relies solely on external monitoring of the fetal heart rate and maternal contractions, making it noninvasive and straightforward.
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