A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

"Why would you think a thing like that?"

"What would your family do without you?"

"Are you thinking of hurting yourself?"

"When you get better you will not feel this way."

Answer and Explanation

The Correct Answer is C

A. "Why would you think a thing like that?": This is incorrect. Asking “why” could make the client feel defensive or that their feelings are being dismissed, which can hinder further conversation. It is important to approach suicidal statements with sensitivity and direct concern.

B. "What would your family do without you?": This is incorrect. While this may seem like a caring response, it places responsibility on the client to think about their family, which may not be helpful if they are feeling overwhelmed by their own emotions. The focus should be on the client’s safety and well-being.

C. "Are you thinking of hurting yourself?": This is correct. It is essential to directly assess the client's safety when they express suicidal thoughts. Asking this question shows concern for the client’s immediate safety and opens the door for further discussion on their feelings and potential plans.

D. "When you get better you will not feel this way.": This is incorrect. This response may dismiss the client’s current feelings and suggests that their emotions are temporary, which could undermine the seriousness of their statements. It is important to validate the client's feelings and address their safety directly.

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Correct Answer is A

Explanation

A. Place a pillow under the child's head: This is correct. The nurse should place a soft object, such as a pillow or folded blanket, under the child’s head to prevent head injury during a seizure. It is important to protect the patient from harm without interfering with the seizure.

B. Turn the child onto their back: This is not advisable during a seizure. The child should remain in a safe position, preferably on their side to help maintain the airway and prevent aspiration. Turning onto their back is not a first-line intervention.

C. Place a padded tongue blade in the child's mouth: This is incorrect. A padded tongue blade should never be inserted into the mouth during a seizure, as it can cause dental or oral injury, and may lead to aspiration or choking.

D. Restrain the child's upper extremities: Restraining the child is not recommended during a seizure. The child should not be physically restrained during the event, as this could cause injury or increase the risk of aspiration. The nurse should focus on providing safety and not interfering with the natural movements during a seizure.

A. The telephone numbers of the clients B. The room numbers of the clients C. The diagnoses of the clients D. The names of the clients' nearest relatives

Correct Answer is A

Explanation

A. Using the telephone numbers of the clients is correct. According to The Joint Commission's National Patient Safety Goals, at least two unique identifiers, such as date of birth and telephone number, should be used to verify client identity before administering medications to prevent errors.

B. Using the room numbers of the clients is incorrect. Room numbers can change, and relying on them increases the risk of medication errors if a client is moved or misidentified.

C. Using the diagnoses of the clients is incorrect. A diagnosis is not a unique identifier, as multiple clients in a unit may have the same or similar conditions, leading to potential confusion.

D. Using the names of the clients' nearest relatives is incorrect. Family members’ names do not provide a direct, unique way to verify the client’s identity, making them unreliable for medication administration.

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A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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