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
After a laparoscopic cholecystectomy, steri-strips or adhesive strips are commonly placed over the small incisions. The client should keep the steri-strips in place until they fall off on their own or until they are removed by the healthcare provider during a follow-up visit. Removing the steri-strips prematurely can increase the risk of infection or disrupt the healing process.
"I should eat a high-fat diet for several weeks": After a laparoscopic cholecystectomy, it is important for the client to follow a low-fat diet initially to allow the body time to adjust to the absence of the gallbladder. High-fat foods can be more difficult to digest and may cause digestive discomfort. Gradually introducing small amounts of fat back into the diet is recommended, but a high-fat diet is not appropriate.
"I should expect to have diarrhea until my diet changes": While changes in bowel movements can occur after a cholecystectomy, such as looser stools or changes in frequency, persistent diarrhea is not expected or normal. If the client experiences persistent diarrhea, they should contact their healthcare provider for further evaluation.
"I should expect to have nausea for several days": While some clients may experience mild nausea or discomfort after the surgery, it should generally improve within a few days. If the client experiences persistent or severe nausea, they should contact their healthcare provider.
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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