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?

When you get better you will not feel this way.

Why would you think a thing like that?

What would your family do without you?

Are you thinking of hurting yourself?

Answer and Explanation

The Correct Answer is D

Are you thinking of hurting yourself?

When a client expresses thoughts of self-harm or suggests that others would be better off without them, it is essential for the nurse to assess for suicidal ideation and ensure the client's safety. Asking directly about thoughts of self-harm is an appropriate and crucial response in this situation.

When you get better you will not feel this way in (option A) is incorrect. This response minimizes the client's feelings and does not address the seriousness of the situation. It is important to assess the client's immediate safety before discussing long-term improvement.

Why would you think a thing like that? In (option B) is incorrect. This response may come across as judgmental or dismissive of the client's feelings. It is essential to provide a supportive and non- judgmental environment for the client to express their thoughts and concerns.

What would your family do without you? In (option C) is incorrect This response also minimizes the client's feelings and does not address the underlying issue. It is crucial to focus on the client's immediate safety and well-being rather than shifting the focus to the impact on others.

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Correct Answer is A

Explanation

A respiratory rate of 8 breaths per minute with shallow respirations and cyanosis indicates significant respiratory distress and inadequate oxygenation. The client's airway needs to be assessed and cleared to ensure a proper flow of air into the lungs. This can involve positioning the client appropriately, providing manual or mechanical assistance with ventilation, or using other airway management techniques as necessary.
While administering oxygen to the client and placing a pulse oximeter on the client's finger are important interventions to improve oxygenation and monitor oxygen saturation, they should not delay the immediate priority of establishing a patent airway.
Checking the client's pulse rate is also important and should be done in a timely manner, but it should not take precedence over ensuring a clear and open airway for the client.

A. Sleep apnea B. Disorientation C. Tonic-clonic seizures D. Paresthesias

Correct Answer is B

Explanation

Disorientation is a common side effect of ECT and is typically temporary. It may include confusion and difficulty recalling recent events or personal information. This post-treatment disorientation is often referred to as the "postictal state" and usually resolves within a short period of time.

Sleep apnea, tonic-clonic seizures, and paresthesias are not expected findings following ECT and would require immediate attention and intervention if they were to occur. It is important for the nurse to closely monitor the client's vital signs, oxygen saturation levels, and neurological status after the procedure to ensure their safety and well-being.

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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

A nurse is caring for a client who is cyanotic and has a respiratory rate of 8/min with shallow respirations. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client following electroconvulsive therapy for the treatment of a depressive disorder. Which of the following findings should the nurse expect 15 min following the procedure?

Correct Answer is B

Explanation

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