A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?
"Have you been thinking about harming yourself?"
"Why do you feel like things will never work out?"
“You should try to focus on yourself for a change."
“Maybe an antidepressant will make you feel better."
The Correct Answer is A
A. This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B. Asking the client a why question may not be alright and this may make them to be guarded.
C. This response may come off as dismissive and lacks empathy towards the client's feelings.
D. Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
Blood pressure Potential worsening: The blood pressure dropped from 114/64 mm Hg on Day 1 to 98/56 mm Hg on Day 2, indicating a potential worsening as it decreased.
Gait when ambulating - Potential worsening: The client's gait was noted to be uncoordinated when ambulating to the bathroom on Day 2, suggesting a potential worsening in motor coordination or balance.
Lithium level Potential worsening: The lithium level increased from 1.9 mEq/L on Day 2, exceeding the therapeutic range (less than 1.5 mEq/L), indicating a potential worsening due to lithium toxicity.
Urine amount and color - Potential worsening: polyuria is a sign of lithium toxicity.
Blurred vision Potential worsening: The client reports blurred vision and frequently rubs their eyes on Day 2, indicating a potential worsening of visual acuity or ocular health.
Correct Answer is ["B","C","D"]
Explanation
A. Clients have the right to refuse medication, as part of their autonomy and informed consent rights.
B. Clients retain their right to privacy and confidentiality, which are fundamental rights in healthcare and protected under various laws and regulations.
C. Clients have the right to the least restrictive environment necessary for their treatment, which supports their freedom and dignity.
D. Clients maintain the right to an attorney, ensuring their access to legal representation and support.
E. Clients can withdraw consent at any time, even after signing an informed consent form, as part of their ongoing right to informed consent and autonomy.
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