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 {"dropdown-group-1":"D"}
Explanation
The nurse should prepare to administer naloxone and oxygen 10 L/min via face mask. Naloxone is a medicine that can reverse the effects of opioid drugs like fentanyl, which may have caused respiratory depression in the client.
Oxygen can help improve the client's oxygen saturation, which has dropped below 90%.
The nurse should avoid giving acetaminophen, which is not indicated for this situation, or additional doses of propofol or fentanyl, which may worsen the client's condition.
Correct Answer is C
Explanation
The correct answer is C. "Close your mouth around the mouthpiece." The rationale for this instruction is that it ensures that the medication reaches the lungs and does not escape through the mouth or nose. Albuterol is a bronchodilator that relaxes muscles in the airways and increases airflow to the lungs. It is used to treat or prevent bronchospasm, or narrowing of the airways, in people with asthma or certain types of chronic obstructive pulmonary disease (COPD). It is also used to prevent exercise-induced bronchospasm. Albuterol is delivered through a metered dose inhaler (MDI), which is a device that releases a measured amount of medication with each puff. To use an albuterol MDI correctly, the client should follow these steps :
- Shake the inhaler well before each spray.
- Remove the cap and look at the mouthpiece to make sure it is clean.
- Breathe out fully.
- Put the mouthpiece between your lips and close your mouth around it.
- Press down on the inhaler to release the medication as you start to breathe in slowly.
- Breathe in slowly and deeply over 3 to 5 seconds.
- Hold your breath for 10 seconds to allow the medication to reach your airways.
- Breathe out slowly.
- If you need another puff, wait 1 minute and repeat steps 4 to 8.
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