A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse. "I want to die now that my partner is gone." Which of the following responses should the nurse make?
"Tell me more about your partner."
"Have you thought about harming yourself?"
"Why did you stop taking your medication?
"You should discuss these feelings with your provider."
The Correct Answer is B
A. "Tell me more about your partner.":
While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.
B. "Have you thought about harming yourself?":
This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.
C. "Why did you stop taking your medication?":
While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.
D. "You should discuss these feelings with your provider.":
This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Combining medications with the formula in the feeding bag:
This is not recommended because it may lead to interactions between the medications and the enteral feeding formula. Medications may also adhere to the tubing or interfere with the absorption of nutrients from the feeding formula.
B. Diluting each crushed medication with warm water:
While diluting medications may be necessary for some drugs, it is not a general rule for all medications. Additionally, dilution with warm water may not be appropriate for all drugs, and the amount of water needed may vary. It's safer to use a standardized method, such as flushing the tube with sterile water.
C. Mixing the medications together in a single syringe:
This is generally not recommended because different medications may have incompatible properties or form precipitates when mixed together. Mixing medications in a single syringe can compromise the effectiveness of each medication and may lead to unpredictable reactions.
D. Flush the NG tube with 5 mL of sterile water for irrigation prior to administration:
Flushing the tube with sterile water helps ensure that the tube is clear of any residual formula, preventing potential interactions between the medication and the enteral feeding. It also helps clear the tube, reducing the risk of clogs or blockages. Using sterile water helps maintain aseptic technique.
Correct Answer is D
Explanation
A. Elevate full-length side rails on both sides of the client's bed:
While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.
B. Place the bedside table 0.9 m (3 feet) away from the bed:
Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.
C. Keep the client's room temperature at 18°C (64.4°F):
While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.
D. Provide the client with a night light:
This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.
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