A nurse is caring for a client who has recently undergone a bilateral mastectomy. The client states they do not want to live anymore. Which of the following actions should the nurse take?
Discuss the client's strengths and weaknesses with the client.
Ask the client to clarify what they mean.
Ask the client if they have been taking their medication as prescribed.
Remind the client that it is not the end of life.
The Correct Answer is B
A. Discuss the client's strengths and weaknesses with the client: Exploring strengths can be part of long‑term therapeutic support, but it does not address the immediate concern of a possible suicidal statement. Before engaging in broader discussions, the nurse must first determine the meaning and seriousness of the client’s words.
B. Ask the client to clarify what they mean: Asking the client to clarify their statement is the priority because it directly assesses the risk of self‑harm. This step helps the nurse determine whether the client has suicidal ideation, intent, or a plan. Clear assessment of safety concerns must occur before any other supportive or therapeutic interventions.
C. Ask the client if they have been taking their medication as prescribed: Medication adherence is important, but it does not address the urgency of a suicidal comment. Focusing on medications can divert attention from immediate safety needs and delay critical assessment of suicidal risk.
D. Remind the client that it is not the end of life: Offering reassurance without assessing the client’s emotional state can minimize their feelings and discourage further communication. This response may shut down dialogue and does not evaluate the level of risk, which is the most urgent priority.
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Related Questions
Correct Answer is A
Explanation
A. Health department data and statistics reports: Local or state health departments routinely collect and publish epidemiological data, including incidence and prevalence rates of communicable diseases like tuberculosis. These reports provide reliable, up-to-date statistics that are essential for planning and evaluating public health programs.
B. Expert opinion from local health care providers: Expert opinion can provide insights into trends or clinical observations, but it is anecdotal and not sufficient for calculating incidence rates. Public health planning requires data that is systematically collected and analyzed.
C. Browsing an internet search engine: While internet searches may yield general information, the results may not be accurate, up-to-date, or specific to the local population. Official health department sources are more reliable for incidence data.
D. Clinical guidelines from a professional organization: Clinical guidelines provide recommendations for diagnosis, treatment, and management, but they do not usually include local incidence statistics. They are not a primary source for epidemiological data.
Correct Answer is C
Explanation
A. The infant is swaddled but there is a blanket and a stuffed toy in the crib. Loose items increase the risk of suffocation and SUID, so this does not demonstrate safe sleep practices.
B. The infant is placed on their back, but there is a blanket and a stuffed toy in the crib. These items pose a suffocation risk and do not follow safe sleep guidelines.
C. The infant is placed on their back in a swaddle with no loose blankets or toys in the crib. This position aligns with American Academy of Pediatrics (AAP) recommendations for safe sleep to reduce the risk of SUID, demonstrating proper understanding of safe sleep practices.
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