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. Allow the antiseptic to dry before puncturing.: This is correct. It is important to allow the antiseptic (such as alcohol) to dry before puncturing the skin. If the antiseptic is not allowed to dry, it can cause hemolysis of the blood sample and lead to inaccurate glucose readings.

B. Apply sterile gloves.: This is incorrect. While gloves should be worn to maintain hygiene and safety, non-sterile gloves are sufficient for a capillary blood glucose test. Sterile gloves are not necessary unless the procedure requires aseptic technique.

C. Hold the lancet at a 45° angle.: This is incorrect. The lancet should be held at a 90° angle to the skin to ensure a proper and clean puncture.

D. Massage the client's finger away from the puncture site.: This is incorrect. The finger should not be massaged before or after the puncture site because it can cause tissue damage and lead to inaccurate blood samples due to the mixing of interstitial fluid with the blood sample.

A. "This must be very frightening for you. Let's talk more about it." B. "What makes you think the staff is following you?" C. “Why do you feel the staff is the FBI?" D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is A

Explanation

A. "This must be very frightening for you. Let's talk more about it.": This response demonstrates empathy and validation of the client's feelings, which can help build trust. It acknowledges the client's emotional state while not challenging or confronting their delusion directly. This approach helps maintain rapport while encouraging the client to express themselves.

B. "What makes you think the staff is following you?": This response could be perceived as questioning the validity of the client's experience, which may feel confrontational or invalidating. It is not the best approach for engaging a client with paranoid delusions.

C. “Why do you feel the staff is the FBI?": This question could also challenge the client's delusion and inadvertently reinforce their sense of being persecuted. Asking such a question might escalate anxiety rather than calm the client.

D. "The psychiatric staff is not FBI. They are here to help you.": While this response is factually correct, it may be perceived as dismissive of the client's experience. Confronting the delusion directly is generally not helpful and can increase the client's feelings of mistrust.

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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?

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