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."
"Are you thinking of hurting yourself?"
"What would your family do without you?"
"Why would you think a thing like that?"
The Correct Answer is B
The correct answer is B. The nurse should assess the client's risk for suicide by asking directly about suicidal thoughts or plans. This is a priority intervention that can help prevent harm to the client and provide appropriate referrals for further evaluation and treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.
Choice B reason:
Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag
Choice C reason:
Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.
Choice D reason
Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.
Correct Answer is A
Explanation
The mother and the baby should have matching identification bands to prevent abduction or mix-up.
The mother should not remove her security band, as this can compromise her identity and safety.
The mother should not take her baby to the lobby or other public areas, as this can expose the baby to infection or harm.
The mother should use a bassinet or crib to transport her baby to the nursery, as this can prevent falls or injuries.
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