A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?
"You should try to focus on yourself for a change."
"Why do you feel like things will never work out?"
"Have you been thinking about harming yourself?"
"Maybe an antidepressant will make you feel better."
The Correct Answer is C
Choice A reason:
Telling a client to focus on themselves for a change may come across as dismissive and does not address the underlying feelings of hopelessness. It is important for the nurse to acknowledge the client's feelings and provide support rather than suggesting a shift in focus without understanding the root cause of their distress.
Choice B reason:
Asking the client why they feel like things will never work out can be a useful way to explore their thoughts and feelings. However, it may not be the most immediate concern if the client is experiencing severe hopelessness or suicidal ideation. The nurse should prioritize assessing the client's safety and risk of self-harm.
Choice C reason:
Asking if the client has been thinking about harming themselves is crucial in assessing their safety. Suicidal ideation is a serious concern, and it is important for the nurse to directly address this issue to determine if the client is at risk of self-harm. This response shows that the nurse is taking the client's feelings seriously and is concerned about their well-being.
Choice D reason:
Suggesting an antidepressant might make the client feel better can be helpful in the long term, but it does not address the immediate emotional distress the client is experiencing. Medication can be part of a treatment plan, but the nurse should first ensure the client's immediate safety and provide emotional support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
Choice A reason:
Placing the client in a reclining chair is not a recommended intervention for managing wandering behavior. While it might seem like a way to keep the client stationary, it does not address the underlying issue of wandering and can lead to discomfort or pressure sores if the client remains in the chair for extended periods.
Choice B reason:
Installing sensor devices on outside doors is an effective intervention. These devices can alert caregivers when the client attempts to leave the house, thereby preventing wandering and potential falls. This measure enhances safety by providing immediate notification of the client's movements.
Choice C reason:
Positioning the mattress on the floor can help prevent injuries from falls. If the client rolls out of bed, the risk of injury is minimized because the fall distance is significantly reduced. This is a practical solution for clients who are prone to falling out of bed.
Choice D reason:
Encouraging physical activity prior to bedtime can be beneficial for overall health but may not be the best strategy for managing nighttime wandering. Physical activity should be balanced and not too close to bedtime, as it can sometimes lead to increased alertness rather than promoting sleep.
Choice E reason:
Putting locks at the top of doors is a useful safety measure. Clients with Alzheimer's disease may not notice or be able to reach locks placed higher up, which can prevent them from wandering outside unsupervised. This intervention helps ensure the client's safety by restricting access to potentially dangerous areas.
Correct Answer is B
Explanation
Choice A reason:
Reinforcing teaching about coping mechanisms is a task that requires clinical judgment and the application of nursing knowledge, which are responsibilities that cannot be delegated to assistive personnel. Nurses are responsible for the initial teaching and ongoing reinforcement of coping mechanisms, as they have the training to assess the client's understanding and provide appropriate education.
Choice B reason:
Sitting with a client during mealtimes does not require clinical judgment or specialized nursing knowledge and can be delegated to assistive personnel. This task involves providing support and encouragement to the client, as well as monitoring the client's intake, which are within the scope of duties that assistive personnel can perform.
Choice C reason:
Discussing relapse prevention with the family of a client who has schizophrenia involves therapeutic communication and education that must be based on nursing assessment and planning. This task requires the nurse's expertise in mental health and cannot be delegated to assistive personnel.
Choice D reason:
Administering a rectal suppository is a medication administration task that involves nursing judgment related to assessing the client's condition and understanding the medication's effects. This task cannot be delegated to assistive personnel, as they are not licensed to administer medications.
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