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 B

Explanation

While addressing self-esteem and positive personality traits is important for overall psychological well-being, it is not the priority during the acute detoxification phase. Ensuring the client's physical safety and stability is the immediate concern.

B. Providing for adequate hydration and rest.

Explanation: The process of detoxification from alcohol can lead to withdrawal symptoms, some of which can be severe and even life-threatening. Adequate hydration is crucial during this period to prevent dehydration and electrolyte imbalances that can occur due to excessive vomiting, diarrhea, or sweating associated with withdrawal. Rest is also important to help the client's body recover from the physical stress of withdrawal.

C. Educating the client about the consequences of alcohol misuse.

Education about the consequences of alcohol misuse is important for the client's understanding and motivation for recovery, but this intervention can come after addressing the immediate physical needs of detoxification.

D. Confronting the use of denial and other defense mechanisms.

Addressing denial and defense mechanisms is a critical aspect of therapy for clients with alcohol use disorder, but it might not be the first priority during the detoxification phase. Ensuring the client's physical safety and managing withdrawal symptoms take precedence initially.

A. "Are you thinking of harming yourself?" B. "Do you really think your family would be better off without you?" C. "When did you first start feeling this way?" D. "Tell me what is happening right now."

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.

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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

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Explanation

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Correct Answer is A

Explanation

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