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

Explanation

Choice A rationale:

Gentamicin is known to have ototoxic effects and can lead to hearing loss, especially when administered via IV infusion. Monitoring for hearing changes is crucial to prevent permanent damage.

Choice B rationale:

Slurred speech is not a common adverse effect of gentamicin. It is more associated with neurological issues or medications affecting the central nervous system.

Choice C rationale:

Hyperthermia is not a typical adverse effect of gentamicin. It may be a sign of infection or another underlying condition but is not directly related to the medication.

Choice D rationale:

Hypotension is not a common adverse effect of gentamicin. It is more commonly associated with medications that affect blood pressure or underlying medical conditions.

A. Relocate the sensor every 8 hrs. B. Wait 10 sec after placing the probe before obtaining the oxygen saturation reading. C. Choose a finger with a capillary refill less than 2 sec. D. Place the sensor probe on the same extremity as an electronic blood pressure cuff.

Correct Answer is C

Explanation

Choice A rationale:

Relocating the sensor every 8 hours is not necessary when obtaining oxygen saturation readings unless there is a specific clinical reason to do so, such as skin irritation or poor perfusion at the sensor site. Frequent relocation can cause unnecessary disruption for the patient.

Choice B rationale:

Waiting 10 seconds after placing the probe before obtaining the oxygen saturation reading is not required. Modern pulse oximeters provide real-time readings, and there is no need to wait after placing the probe. The reading is usually stable within seconds.

Choice C rationale:

Choosing a finger with a capillary refill time of less than 2 seconds is an essential consideration when obtaining oxygen saturation readings. Capillary refill time is a measure of peripheral perfusion, and choosing a finger with good perfusion ensures accurate oxygen saturation measurements.

Choice D rationale:

Placing the sensor probe on the same extremity as an electronic blood pressure cuff is generally acceptable. However, it is crucial to ensure that the sensor does not interfere with the blood pressure cuff's function and that it is securely attached to the patient's finger for accurate readings.

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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

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Correct Answer is A

Explanation

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Correct Answer is C

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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?