A nurse in a community health clinic is assessing a client who has two preschoolers, was recently divorced, and is seeking help for managing depression. Which of the following questions should the nurse ask first?
"Are you having any thoughts about hurting yourself?"
"Who is available to help you?"
"Could you describe how you are feeling today?"
"Is there anything that makes you feel less depressed?"
The Correct Answer is A
The correct answer is choice A, "Are you having any thoughts about hurting yourself?" This is the most important question to ask because it assesses the client's risk for suicide, which is a potential complication of depression. The nurse should ask this question before exploring other issues related to the client's depression. If the client expresses suicidal thoughts or intent, the nurse should initiate appropriate interventions to ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice B. When caring for clients from different cultural backgrounds, it is important to be respectful and non-judgmental. In this situation, the nurse should ask the family to describe how they hope the treatments will affect their health. This will allow the nurse to gain a better understanding of the family's beliefs and values regarding health and illness. The nurse should avoid making assumptions or judgments about the family's beliefs and should not criticize or dismiss the folk healer. Alternative medicine practices (choice A) can be dangerous in some cases, but it is not appropriate to make a blanket statement that they should be avoided. Suggesting that folk medicine works by providing a placebo effect (choice C) is not respectful of the family's beliefs and is dismissive of their cultural practices. Referring the family to a medical practitioner (choice D) may not be appropriate if the family has a strong belief in folk medicine practices.
Correct Answer is C
Explanation
A.While social withdrawal is a concerning sign of grief, it does not necessarily indicate an immediate risk of self-harm. The nurse should continue to monitor and encourage engagement.
B.Anger is a normal stage of grief. Unless the client expresses intent to harm themselves or others, anger alone does not require immediate intervention.
C.This statement may indicate suicidal ideation. When a grieving client expresses that "everything is going to be fine soon," it can be a red flag for suicidal intent, especially if they have recently experienced a significant loss. Some individuals contemplating suicide may appear calm or overly optimistic once they have decided on a plan.
D.Refusal to communicate is concerning but not necessarily an immediate crisis. The nurse should build rapport and offer ongoing support.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.