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 C
Explanation
"My baby will receive the rotavirus immunization orally." - This statement is correct. The rotavirus vaccine is administered orally, typically as drops or as an oral suspension. It is important for the guardian to follow the specific instructions provided by the healthcare provider for the administration of the rotavirus vaccine.
"I should not feed my baby anything for 2 hours prior to an immunization." - This statement is incorrect. It is not necessary to withhold feeding prior to immunizations. In fact, it is generally recommended to feed the baby before the immunization to help provide comfort during the procedure.
"My baby will receive three doses of the meningococcal immunization before kindergarten." - This statement is incorrect. The number of doses and the schedule for each immunization may vary. The guardian should consult with the healthcare provider or refer to the immunization schedule for specific recommendations regarding meningococcal immunization.
"I should expect my baby to have a high fever for 24 hours after an immunization." - This statement is not entirely accurate. While it is common for infants to experience mild side effects such as a low-grade fever after immunizations, a high fever is less common. The guardian should be aware of the potential side effects and contact the healthcare provider if they have concerns about their baby's reaction to the immunization.
Correct Answer is C
Explanation
The presence of edema and coolness around the catheter's insertion site suggests that infiltration may have occurred. Infiltration refers to the unintended leakage of fluid into the surrounding tissues instead of flowing into the vein. It can lead to tissue damage and compromised circulation. Stopping the infusion is the initial priority to prevent further infiltration and minimize potential harm to the client.
A. Applying a warm compress may be appropriate to promote comfort and circulation in some cases, but it should be done after stopping the infusion and assessing the severity of the infiltration.
B. Documenting the infiltration is necessary for accurate record-keeping and to communicate the occurrence to the healthcare team. However, it is not the first immediate action required in this situation.
D. Elevating the arm can help reduce swelling and promote venous return. It can be done after stopping the infusion, but it is not the first action to address the potential infiltration.
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