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 D
Explanation
Answer: D. I should check my heart rate while taking this medication.
Rationale: Timolol is a beta-blocker that can lower intraocular pressure by reducing aqueous humor production in the eye. However, it can also cause systemic effects such as bradycardia, hypotension, and bronchospasm. Therefore, clients should monitor their heart rate and report any signs of adverse reactions to the provider. Zinc supplements, eye dilation, and eye color changes are not associated with timolol use.
Correct Answer is D
Explanation
The correct answer is D. The nurse should measure the client's vital signs first to assess for any injuries or complications from the fall, such as bleeding, shock, or head trauma. The nurse should then notify the provider and document the fall in the client's medical record. Completing an incident report is also important, but it is not the first action that the nurse should take.
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