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?”

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

Blood pressure: This finding is consistent with preeclampsia, but not HELLP syndrome.Preeclampsia is defined as new-onset hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) after 20 weeks of gestation, with or without proteinuria.HELLP syndrome is a severe form of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelets, but does not necessarily cause hypertension. Hemoglobin: This finding is consistent with HELLP syndrome, but not preeclampsia.

Hemolysis is one of the main features of HELLP syndrome, which causes a decrease in hemoglobin levels.Preeclampsia does not typically affect hemoglobin levels, unless there is significant blood loss or hemodilution.

Platelet count: This finding is consistent with both preeclampsia and HELLP syndrome.Low platelets (thrombocytopenia) are a common complication of preeclampsia, especially in severe cases.They are also a diagnostic criterion for HELLP syndrome, which requires a platelet count of less than 100,000/mm3.

Alanine aminotransferase: This finding is consistent with HELLP syndrome, but not preeclampsia.Elevated liver enzymes are another hallmark of HELLP syndrome, which indicates liver damage and inflammation.Preeclampsia may cause mild elevations of liver enzymes, but not to the same extent as HELLP syndrome.

A. Apply fundal pressure during contractions. B. Encourage the client to soak in a hot bath. C. Instruct the client to change positions frequently. D. Tell the client to push during contractions.

Correct Answer is C

Explanation

Choice A rationale:

"Apply fundal pressure during contractions." - Applying fundal pressure during contractions is not appropriate during the latent stage of labor. Fundal pressure is typically used during the second stage of labor (active pushing phase) to assist with fetal descent. Using it during the latent stage can be harmful.

Choice B rationale:

"Encourage the client to soak in a hot bath." - Soaking in a hot bath is generally not recommended during labor, especially without specific indications. It is essential to maintain the safety and well-being of both the mother and the baby. Encouraging the client to change positions or use comfort measures like relaxation techniques would be more appropriate.

Choice C rationale:

"Instruct the client to change positions frequently." - This is the correct answer. During the latent stage of labor, encouraging the client to change positions frequently can help promote comfort and optimize fetal positioning. Changing positions can reduce discomfort, enhance uterine contractions, and facilitate the progression of labor.

Choice D rationale:

"Tell the client to push during contractions." - Pushing during contractions is typically reserved for the second stage of labor when the cervix is fully dilated. In the latent stage, the cervix is not fully dilated, and pushing prematurely can be harmful and delay labor progress. It is essential to follow the appropriate guidelines for each stage of labor.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Explanation

A nurse is assisting with the care of a client who is in the latent stage of labor and has pelvic pain with contractions.Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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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?