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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Cocaine is a powerful stimulant drug that can cause an acute increase in heart rate and blood pressure. Hypertension is a common clinical manifestation associated with cocaine use due to its sympathomimetic effects, which stimulate the sympathetic nervous system. This can lead to vasoconstriction and increased cardiac output, resulting in elevated blood pressure levels.
Choice B reason:
Hypothermia is not typically associated with cocaine use. Cocaine tends to increase body temperature due to its stimulant properties, which can lead to hyperthermia rather than hypothermia. If hypothermia is present in a client who has used cocaine, it may be due to other factors or substances that the client has ingested.
Choice C reason:
Bradycardia, or a slower than normal heart rate, is not a common effect of cocaine use. Cocaine usually causes tachycardia, an increased heart rate, as part of its stimulant effect on the body. Bradycardia would be an unusual response and might suggest other medical issues or the influence of other substances.
Correct Answer is D
Explanation
Choice A reason:
Having a staff member check on the client every 30 minutes is important for ensuring the client's safety and well-being. However, best practices suggest that continuous visual monitoring or checks at least every 15 minutes is generally recommended. This frequent monitoring allows for prompt identification and response to any distress or needs the client may have.
Choice B reason:
Assessing the client's need for toileting every 15 minutes may be excessive and could potentially cause additional distress or discomfort. The standard practice is to assess for toileting needs less frequently, typically every 2 hours, unless there is a specific indication that more frequent checks are necessary.
Choice C reason:
Asking the provider to renew the prescription for restraints every 8 hours is not aligned with standard guidelines. Restraint orders must be reviewed and renewed according to facility protocols, which usually require renewal every 24 hours. This ensures that the use of restraints is continually justified and that the client's condition is regularly reassessed.
Choice D reason:
Offering hydration and nutrition to the client every 2 hours is a critical aspect of care for a client in restraints. It is essential to meet the client's basic needs and to prevent dehydration and malnutrition. Additionally, providing hydration and nutrition at regular intervals aligns with the guidelines for monitoring and assessing clients in restraints.
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