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 {"dropdown-group-1":"B","dropdown-group-2":"C"}
Explanation
Upon assessment, the nurse should recognize that the client is at risk for developing acute confusion or delirium as evidenced by the client's disorientation to time and place, inability to focus, agitation, and anxiety upon reorientation. These symptoms suggest a disruption in cerebral metabolism, which can be caused by a variety of factors such as infection, fluid or electrolyte imbalance, or medication side effects. It is crucial to identify the underlying cause to provide appropriate care and prevent further complications. The nurse's role includes monitoring the patient's mental status, ensuring safety, and implementing therapeutic interventions to create a calming environment.
Correct Answer is D
Explanation
A. Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B. Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C. Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D. Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.
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