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:
Encourage the client to have continual bed rest. Rationale: Continual bed rest is not the appropriate intervention for a client experiencing chronic fatigue due to leukemia. Prolonged bed rest can lead to further weakness and deconditioning. Encouraging some level of physical activity, such as gentle exercise, can help improve strength and reduce fatigue.
Choice B rationale:
Encourage strength-training exercise. Rationale: This is the correct intervention for a client with leukemia experiencing chronic fatigue. Strength-training exercises, when appropriate and under the guidance of healthcare professionals, can help improve muscle strength and overall endurance. It can combat the fatigue commonly associated with leukemia and its treatment.
Choice C rationale:
Increase the client's fluids to 4 L per day. Rationale: While adequate hydration is essential, increasing fluids to 4 liters per day may not be appropriate for every client. The optimal fluid intake for a client should be determined based on their individual needs and medical condition. Excessive fluid intake without medical indication can lead to complications like fluid overload.
Choice D rationale:
Increase protein in the diet. Rationale: Increasing protein intake can be beneficial for clients with leukemia as it helps in tissue repair and supports the immune system. However, it should be done in consultation with a registered dietitian to ensure that the client's specific dietary needs are met.
Correct Answer is C
Explanation
Choice A rationale:
Documenting the medication error in the provider's progress notes is not the appropriate location for documenting a medication error. Progress notes are typically used to record the client's clinical progress and assessments, not incidents of medication errors.
Choice B rationale:
The controlled substance inventory record is used to track the dispensing and administration of controlled substances in a healthcare facility. Documenting a medication error in this record is not appropriate, as it is not the purpose of this document.
Choice C rationale:
Documenting the medication error in an incident report is the correct action. Incident reports are used to document and track adverse events or errors that occur in healthcare settings. This allows for proper investigation, analysis, and the implementation of preventive measures to avoid similar errors in the future.
Choice D rationale:
The nursing care plan is a document that outlines the client's nursing care needs, goals, and interventions. While it may include information about medication administration, it is not the appropriate place to document a medication error. An incident report is specifically designed for this purpose and ensures that the error is appropriately addressed and investigated.
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