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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
. Autonomy. Autonomy is the ethical principle that upholds a patient's right to make their own healthcare decisions. In this scenario, the nurse acknowledges the patient's right to refuse treatment and informs them that they will support their decision. By doing so, the nurse is respecting the patient's autonomy and their right to make decisions about their own body and treatment.
Correct Answer is D
Explanation
When reviewing home safety precautions with a client who is to begin radioactive iodine therapy, the nurse should emphasize the importance of using a toilet that is not used by others in the family. The client should also flush the toilet several times after use and clean it with household bleach. The nurse should advise the client to use disposable plates, cups, and utensils and to avoid close contact with others, especially pregnant women and children. The client should also avoid sharing towels, linens, and other personal items. Waiting one week after treatment to use a laxative (choice A) and using cloth handkerchiefs instead of tissues (choice B) are not relevant to home safety precautions for this client. Allowing the granddaughter to visit for four hours daily (choice C) may be unsafe, as the client may still be emitting radiation.
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