A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get before she died." Which of the Following statements should the nurse make?

We can call your family in time for them to get here."

tell your family of your concern so that they can be here

I will make sure a staff member is in your room at all times."

I wonder if you are fearful of dying alone."

Answer and Explanation

The Correct Answer is D

A. "We can call your family in time for them to get here."

While involving the family is important, this response assumes that the client's concern is solely about family being present. The client's statement might have deeper emotional layers, such as fear or regret, that should be addressed.

B. "Tell your family of your concern so that they can be here."

This response puts the responsibility on the client to communicate their concerns to the family. The nurse's role is to provide support and facilitate communication, rather than placing the burden on the client.

C. "I will make sure a staff member is in your room at all times."

While ensuring the client is not alone is important, this response doesn't address the client's emotional concerns or open a dialogue about their feelings. Simply having a staff member present might not address the underlying fear or anxiety the client is experiencing.

D. "I wonder if you are fearful of dying alone."

Explanation: The nurse's response empathizes with the client's feelings and invites a conversation about their emotions. It acknowledges the client's concerns and opens the door for a more in-depth discussion about their fears and feelings regarding dying alone. This approach is patient-centered and encourages the client to express their emotions.

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Correct Answer is A

Explanation

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

A. "This medication may increase your blood pressure." B. "Flu-like symptoms are an expected adverse effect of this medication." C. "Avoid becoming overheated while taking this medication." D. "Muscle twitches can occur the first few weeks while taking this medication."

Correct Answer is C

Explanation

A. "This medication may increase your blood pressure."

This statement is incorrect. Risperidone is not typically associated with significant increases in blood pressure. One of the potential side effects of risperidone is orthostatic hypotension, which is a drop in blood pressure when changing positions (e.g., standing up quickly). Therefore, this choice is not the best instruction to include in the teaching.

B. "Flu-like symptoms are an expected adverse effect of this medication."

This statement is incorrect. While risperidone can have side effects, flu-like symptoms are not commonly associated with it. Common side effects of risperidone may include dizziness, drowsiness, weight gain, and movement disorders. Flu-like symptoms are not a typical adverse effect of this medication.

C. "Avoid becoming overheated while taking this medication."

This statement is correct. Risperidone, like many other antipsychotic medications, can interfere with the body's ability to regulate temperature. This can lead to an increased risk of overheating, especially in hot weather or during vigorous physical activity. Therefore, it's important for patients taking risperidone to be cautious and avoid becoming overheated, as this could potentially lead to heat-related complications.

D. "Muscle twitches can occur the first few weeks while taking this medication."

This statement is incorrect. Muscle twitches are not a common side effect of risperidone. While it's true that some movement disorders can occur with antipsychotic medications, the statement is too specific to muscle twitches and does not accurately reflect the typical side effect profile of risperidone.

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A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get before she died." Which of the Following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?

Correct Answer is A

Explanation

A nurse is providing discharge teaching to a client who is taking risperidone. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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