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 D
Explanation
Including the client's physical assessment findings will provide important information to the physical therapist regarding the client's current condition, limitations, and areas that require rehabilitation or therapy.
While family medical history is important for comprehensive healthcare, it may not be specifically relevant to the referral for a physical therapist unless there is a specific genetic or familial condition that could impact the therapy or rehabilitation process.
Medical health insurance claims are primarily related to billing and reimbursement and may not provide pertinent information to the physical therapist unless there are specific coverage limitations or requirements that need to be considered.
While medication history is important for overall healthcare management, it may not be directly relevant to the referral for a physical therapist unless there are specific medications that could affect the therapy or rehabilitation process (e.g., medications that may cause drowsiness or affect balance).
Correct Answer is B
Explanation
Splinting the incision with a pillow when changing positions can provide support and help minimize discomfort and pain in clients who have undergone a cesarean birth. It can help reduce strain on the incision site and provide a sense of stability and comfort.
A. "You can apply counterpressure to your back with each position change" may be helpful for managing back pain, but it does not specifically address the client's request for nonpharmacological interventions to manage pain when changing positions after a cesarean birth.
C. "You should change positions as little as possible" is not an appropriate response as it does not address the client's need to manage pain when changing positions. Encouraging movement and position changes, along with appropriate support, can aid in recovery and prevent complications such as blood clots and respiratory issues.
D. "You should use patterned-paced breathing when changing positions" is not specifically related to managing pain when changing positions after a cesarean birth. While breathing techniques can be useful for pain management during labor and certain procedures, they may not be the most effective strategy for managing pain when changing positions post-cesarean.
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