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A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die."

Which of the following responses should the nurse make?

A.

"I'm sure your family does not want you to die."

B.

"Why would you believe such things?"

C.

"How does this make you feel?"

D.

"You should talk to your family about your feelings."

Answer and Explanation

The Correct Answer is C

"How does this make you feel?"

  • A. "I'm sure your family does not want you to die." is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's own assumptions. This choice is incorrect.
  • B. Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, which can increase the client's defensiveness and resistance. This choice is incorrect.
  • C. "How does this make you feel?" is a therapeutic response, as it encourages the client to express and explore their emotions, which can help to build rapport and trust with the nurse. This choice is correct.
  • D. "You should talk to your family about your feelings." is not a therapeutic response, as it implies that the client is responsible for resolving their own problems and that their family is willing and able to listen and support them, which may not be true. This choice is incorrect.


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Related Questions

Correct Answer is B

Explanation

Jaundice.

Rationale:

  • A. Weight loss is not a common or serious adverse effect of valproic acid. Valproic acid can cause weight gain, not weight loss.
  • B. Jaundice is a sign of liver damage, which is a serious and potentially fatal adverse effect of valproic acid. Valproic acid can impair fatty acid metabolism and mitochondrial function, leading to hepatotoxicity and steatosis. The nurse should monitor the client's liver function tests and report any signs of jaundice, such as yellowing of the skin or eyes, dark urine, or clay-colored stools .
  • C. Bradycardia is not a common or serious adverse effect of valproic acid. Valproic acid can cause cardiac arrhythmias, but they are usually tachycardic, not bradycardic.
  • D. Polyuria is not a common or serious adverse effect of valproic acid. Valproic acid can cause hypernatremia and hypocalcemia, which can affect urine output, but polyuria is not a specific symptom of these electrolyte imbalances.

Correct Answer is D

Explanation

A. The nurse places the client on airborne precautions: This is appropriate, as measles is transmitted via airborne particles. B. The nurse has the client wear a mask for transport to radiology: This is correct. A surgical mask minimizes the risk of spreading airborne pathogens during transport. C. The nurse wears an N95 respirator when performing client care: Correct. An N95 respirator is necessary for protection against airborne diseases like measles. D. The nurse ensures the client's room maintains a positive airflow: This is incorrect and requires intervention. Clients with airborne infections like measles must be placed in negative pressure rooms, which prevent contaminated air from escaping into other areas. Positive airflow increases the risk of transmission to others.

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