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 B
Explanation
Choice A reason
While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.
Choice B reason.
Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure
Choice C reason:
While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.
Choice D reason:
Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.
Correct Answer is B
Explanation
The correct answer is choice B. Nontender, protruding abdomen.
Choice A rationale:
Natural loss of deciduous teeth typically begins around the age of 6 years, not at 2 years. At 2 years old, toddlers are still in the process of getting their primary teeth.
Choice B rationale:
A nontender, protruding abdomen is a normal finding in toddlers due to their developing abdominal muscles and the typical posture of a toddler.
Choice C rationale:
By the age of 2, a child’s head circumference should no longer exceed their chest circumference. This is a characteristic of infants, not toddlers.
Choice D rationale:
Palpable fontanels are expected in infants. By the age of 2, the anterior fontanel should have closed, making it non-palpable.
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