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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Case manager:

The nurse manager, in this context, is not functioning as a case manager. Case management typically involves coordinating and managing the overall care plan for a client over time, including coordination of resources and services.

B. Client care provider:

The nurse manager, in this scenario, is functioning as a client care provider. By observing the newly licensed nurse perform a straight catheterization, the nurse manager is directly involved in overseeing and ensuring the safety of the client care being provided.

C. Client advocate:

While advocacy for the client is a crucial role for all nurses, the specific action described (observing the procedure) is more aligned with the role of a client care provider. Advocacy involves supporting and safeguarding the client's rights and well-being, which can be done in various nursing roles.

D. Client educator:

The nurse manager is not functioning as a client educator in this specific situation. Client education involves providing information and instruction to the client to promote their understanding and participation in their care. The nurse manager's role here is more focused on direct observation and supervision of a clinical skill.

A. Elevate full-length side rails on both sides of the client's bed. B. Place the bedside table 0.9 m (3 feet) away from the bed. C. Keep the client's room temperature at 18° C (64.4" F). D. Provide the client with a night light.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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