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 C
Explanation
A. "Define the problem.": While defining the problem is important in the early stages of performance improvement, evaluating effectiveness requires looking at data or outcomes, not just the initial identification of the issue.
B. "Identify data collection methods.": Identifying data collection methods is part of the planning phase, but evaluating the effectiveness involves reviewing actual data to see if the goals of the program were achieved.
C. "Perform chart audits.": This is correct. Performing chart audits allows the nurse to assess if the desired improvements have been implemented and whether the performance outcomes are being met. Chart audits are a common method for evaluating the effectiveness of a performance improvement program.
D. "Review the facility's policy and procedure manual.": While reviewing policies is important for understanding standards of care, it does not directly evaluate the effectiveness of a performance improvement program. Data from actual practice, such as chart audits, would be more relevant for evaluation.
Correct Answer is C
Explanation
A. Tonic-clonic seizures: This is not typically expected following electroconvulsive therapy (ECT). ECT can induce a brief seizure during the procedure, but the nurse would not expect tonic-clonic seizures afterward as a direct result.
B. Paresthesias: Paresthesias (tingling or numbness) are not commonly associated with ECT. The procedure primarily affects the brain, and while some neurological symptoms may occur temporarily, paresthesias are not expected findings.
C. Disorientation: This is correct. It is common for clients to experience disorientation and confusion immediately following ECT, as it can affect memory and cognition temporarily. This typically resolves within a short period of time (minutes to hours) following the procedure.
D. Sleep apnea: Sleep apnea is not a direct or common effect of ECT. While anesthesia used during the procedure may cause some temporary respiratory changes, sleep apnea would not be expected as a typical post-procedure finding.
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