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?
"What would your family do without you?”
"When you get better you will not feel this way.”
"Why would you think a thing like that?”
"Are you thinking of hurting yourself?”
The Correct Answer is D
Choice A rationale:
Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.
Choice B rationale:
Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.
Choice C rationale:
Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.
Choice D rationale:
This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
The administration of Rh(D) immune globulin (RhoGAM) is typically indicated for Rh-negative mothers who are carrying Rh-positive fetuses to prevent sensitization to Rh antigens. It is not directly related to the amniocentesis procedure. Therefore, this information is not necessary for the client undergoing an amniocentesis.
Choice B rationale:
This is the correct answer. Having an empty bladder is crucial during an amniocentesis procedure because a full bladder can obscure visualization of the fetus and the needle placement. It is essential for a successful and safe procedure. The nurse should instruct the client to empty their bladder before the test.
Choice C rationale:
The position during an amniocentesis is typically dorsal recumbent or semi-Fowler's position to allow for proper visualization of the fetus and needle placement. Lying on the left side is not a standard position for this procedure, so this information is incorrect and not necessary for the client.
Choice D rationale:
Drinking 50 grams of oral glucose is not a requirement for an amniocentesis procedure. This information is unrelated to the amniocentesis and can be confusing for the client. Therefore, it is not necessary to include this in the instructions.
Correct Answer is D
Explanation
Choice A rationale:
Tape the tube to the child's cheek. Taping the tube to the child's cheek is not the recommended method for securing a gastrostomy enteral tube. It can cause discomfort and skin irritation for the child. Proper securing methods involve using specialized tube holders or dressings designed for this purpose.
Choice B rationale:
Apply water-soluble lubricant to the site. Rationale: Applying a water-soluble lubricant to the site is not a standard practice for gastrostomy tube care. It is essential to keep the site clean and dry to prevent infection. Lubricants are not typically used in this context.
Choice C rationale:
Attaching an extension tube is related to administering feedings or medications rather than the maintenance and care of the gastrostomy site. Site care focuses on protecting the skin and ensuring cleanliness around the tube insertion area.
Choice D rationale:
Apply a skin barrier protectant to the site. Using a skin barrier protectant helps shield the peristomal skin from irritation and breakdown caused by gastric contents and formula leakage.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.