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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Measure the duration of the seizure. This is the correct action. Monitoring the duration of the seizure is important for assessing its severity and deciding when to intervene medically. A seizure lasting longer than 5 minutes requires immediate intervention.
B. Lower the side rails of the bed when the seizure begins. This is not recommended. The side rails should be raised to protect the client from injury. Lowering them could increase the risk of falling out of bed.
C. Insert an oral airway into the client's mouth. This is incorrect. Inserting an airway into the mouth during a seizure can be dangerous and may result in injury to the client or the nurse. The client’s airway should be kept clear, but inserting an object into the mouth is not recommended.
D. Restrain the client's arms and legs to prevent injury. This is incorrect. Restraining the client during a seizure can cause injury to both the client and the nurse. It is better to allow the seizure to proceed naturally while ensuring the client is protected from injury (e.g., by placing a soft pillow under their head or cushioning hard surfaces around them).
Correct Answer is D
Explanation
A. "It is my responsibility to obtain informed consent from the client prior to the procedure." is incorrect. It is the provider's responsibility to explain the procedure, its risks, benefits, and alternatives to the client, not the nurse's. The nurse's role is to witness the signing of the consent form.
B. "I will sign the consent form to indicate that the client has received written materials explaining the procedure." is incorrect. The nurse's role is to witness the client's signature, but the nurse does not sign to indicate that the client has received written materials.
C. "I will provide the client with an explanation of the procedure before I sign the consent form." is incorrect. The nurse should not provide the explanation of the procedure; this is the responsibility of the provider. The nurse ensures that the client understands and is signing voluntarily.
D. "When I sign the consent form, I am stating that the client appears to be competent to give consent." is correct. The nurse’s role is to witness the signing of the consent form and ensure that the client appears to be competent to provide consent. The nurse does not provide the explanation but confirms that the client is signing voluntarily and understands the procedure.
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