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:
Placing a pulse oximeter on the client's finger to assess oxygen saturation is important, but in this scenario, establishing a patent airway takes priority. The client's cyanosis and shallow respirations indicate a severe respiratory distress, and the nurse should first ensure the client's ability to breathe before assessing oxygen levels.
Choice B rationale:
Establishing a patent airway is the priority action because the client's shallow respirations and cyanosis indicate a compromised airway and inadequate oxygenation. Ensuring a clear airway is crucial for the client's survival.
Choice C rationale:
Checking the client's pulse rate is an important assessment but should not take precedence over addressing the airway and breathing issues. The client's respiratory distress is a more immediate concern.
Choice D rationale:
Administering oxygen is an appropriate intervention, but it should not be done before ensuring a patent airway. The nurse must prioritize actions to address the most critical issue first.
Correct Answer is A
Explanation
Choice A rationale:
The nurse is demonstrating advocacy by contacting the provider to return and speak with the client when the client expresses a lack of understanding about their diagnosis. Advocacy involves promoting the client's best interests, ensuring they receive appropriate information and care, and facilitating communication between the client and the healthcare team to address their concerns and needs.
Choice B rationale:
Good manners, while important in nursing practice, do not capture the essence of the nurse's action in this scenario. The nurse's primary role is to advocate for the client's understanding and communication with the healthcare provider.
Choice C rationale:
Customer service is not the primary focus in this situation. While providing excellent customer service is important in healthcare, the nurse's primary responsibility is to ensure the client's understanding of their diagnosis and address any questions or concerns they may have.
Choice D rationale:
Kindness is a positive quality in nursing practice, but it does not fully encompass the nurse's role in this scenario. The nurse's primary responsibility is to advocate for the client's understanding and facilitate effective communication with the provider to address the client's concerns and questions.
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