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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["31"]
Explanation
Calculation:
- Identify the total volume, infusion time, and drop factor
Total Volume: 500 mL
Infusion Time: 4 hours (240 minutes)
Drop Factor: 15 gtt/mL
- Calculate the infusion rate in gtt/min
Infusion Rate (gtt/min) = (Total Volume × Drop Factor) ÷ Time (min)
Infusion Rate = (500 × 15) ÷ 240
Infusion Rate = 7500 ÷ 240
Infusion Rate = 31.25 gtt/min
- Round to the nearest whole number
= 31 gtt/min
Correct Answer is B
Explanation
A. Beneficence: Beneficence refers to the ethical principle of promoting good and acting in the best interest of the client. While this guides nursing actions to provide beneficial care, it does not directly involve respecting a client’s decision to refuse treatment.
B. Autonomy: Autonomy is the ethical principle that recognizes the client’s right to make independent decisions about their own healthcare. Respecting the client’s decision to refuse treatment honors their personal values, beliefs, and right to self-determination, even if the nurse disagrees with the choice.
C. Nonmaleficence: Nonmaleficence involves the obligation to avoid causing harm to the client. While important in all nursing actions, it focuses on preventing harm rather than specifically supporting a client’s right to make healthcare decisions.
D. Justice: Justice refers to fairness in the distribution of healthcare resources and treatment. It ensures equitable care for all clients but is not directly related to respecting an individual client’s choice to accept or refuse treatment.
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