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 D

Explanation

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect. The drainage bag should always be kept below the level of the bladder to prevent urine backflow, which can lead to infections (catheter-associated urinary tract infections - CAUTIs).

B. Coiling the tubing on the bed above the collection bag is incorrect. Tubing should be secured below bladder level without kinks or loops to allow for continuous urine drainage and prevent urinary stasis and infection.

C. Collecting a sterile specimen from the urinary drainage bag is incorrect. Urine in the drainage bag is not sterile and may contain bacteria, leading to inaccurate results. A specimen should be collected from the designated port on the catheter tubing using aseptic technique.

D. Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.

A. The client develops chest pain each time he talks about his partner. B. The client keeps a framed picture of his partner on the wall. C. The client reports he has no interest in dating. D. The client attends a grief support group twice each month.

Correct Answer is A

Explanation

A. The client develops chest pain each time he talks about his partner is an indication of complicated grief. The client’s experience of intense, physical symptoms like chest pain when discussing their partner suggests that the grief process may not be progressing and could indicate unresolved or complicated grief.

B. The client keeps a framed picture of his partner on the wall is a normal expression of grief. Keeping a picture of a lost loved one is common and doesn’t necessarily indicate complicated grief. It can be part of the natural grieving process.

C. The client reports he has no interest in dating is not necessarily a sign of complicated grief. It's common for people grieving to not have an interest in dating or forming new romantic relationships immediately after the loss, but it does not suggest a problem unless the client expresses prolonged avoidance of all social interaction.

D. The client attends a grief support group twice each month is a positive coping mechanism. Attending support groups shows the client is actively engaging with the grieving process and seeking support, which is part of healthy adjustment after a loss.

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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 D

Explanation

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Correct Answer is A

Explanation

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