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?
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The AIMS is specifically designed to assess for the presence and severity of abnormal involuntary movements, which can be a side effect of long-term antipsychotic medication use, including tardive dyskinesia. It consists of a series of standardized movements and observations that assess different body regions for abnormal movements. The nurse can use this tool to monitor the client's movements and identify any signs of tardive dyskinesia.
A. Mental Status Examination (MSE): The MSE is a comprehensive assessment of a client's mental status, including their cognition, mood, and thought processes. While the MSE is an important tool in assessing overall mental health, it is not specific to tardive dyskinesia.
C. Patient Health Questionnaire-9 (PHQ-9): The PHQ-9 is a screening tool for depression that assesses the severity of depressive symptoms. While depression can be a comorbidity in individuals with schizophrenia, the PHQ-9 does not directly assess for tardive dyskinesia.
D. Brief Psychiatric Rating Scale (BPRS): The BPRS is a rating scale used to assess the severity of psychiatric symptoms in individuals with mental disorders. While it is useful in evaluating overall symptomatology in schizophrenia, it does not specifically target tardive dyskinesia.
Correct Answer is D
Explanation
A. Artificial flowers in the room: While artificial flowers can harbor dust and allergens, they are not a significant risk factor for infection in a neutropenic client with HIV. The primary concern is bacterial or fungal exposure, which is unlikely to be significantly affected by artificial flowers.Still, due to the need for a highly sterile environment for neutropenic patients, artificial flowers are typically avoided in clinical settings.
B. Room with negative airflow: A room with negative airflow is designed to prevent airborne pathogens from spreading outside the room. However, this measure is more relevant for clients with contagious respiratory infections (e.g., tuberculosis).
C. Meal tray with hard-boiled eggs: Hard-boiled eggs are generally safe for most clients. However, in a neutropenic client, the risk lies more in raw or undercooked eggs due to potential bacterial contamination (e.g., Salmonella). Hard-boiled eggs are fully cooked and less likely to pose a significant risk.
D. Meal tray with ice cream and fresh fruit: This choice presents a higher risk. Neutropenic clients should avoid fresh fruits (especially unwashed) due to potential bacterial and fungal contamination. Ice cream, although pasteurized, can also harbor bacteria if not handled properly.
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