A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident.
The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
"There's nothing you can do here. You should go home to your children."
"You are feeling drawn in two separate directions."
"Perhaps you could call your children to see how they are doing."
"Don't worry.
The Correct Answer is B
Choice A rationale:
Dismissive and unsupportive: This response discounts the client's son's feelings of guilt and obligation toward their parent. It also implies that the client's son's presence is not valuable, which could further increase their distress.
Undermines the client's son's role as a caregiver: It suggests that the client's son has no responsibilities or ability to contribute to their parent's care, which could diminish their sense of agency and potentially lead to resentment or regret.
Fails to address the underlying emotions: It does not acknowledge the client's son's internal conflict and emotional turmoil, which is essential for providing effective support.
Choice C rationale:
Offers a practical solution, but may not address the core issue: While calling the children could provide temporary reassurance, it may not fully alleviate the client's son's feelings of guilt or anxiety about leaving their parent.
May not be feasible or sufficient: The client's son may need more than a phone call to feel comfortable leaving, and they may not be able to reach their children immediately.
Could be perceived as dismissive: It could suggest that the nurse is minimizing the client's son's concerns and not fully understanding their emotional needs.
Choice D rationale:
Reassuring, but may not address the client's son's guilt: While it provides assurance about the client's care, it does not directly acknowledge or validate the client's son's feelings of guilt or obligation.
Focuses on the client's care, but not the client's son's needs: It prioritizes the physical care of the client, but may overlook the emotional needs of the client's son, who is also a primary stakeholder in the situation.
May not be enough to alleviate the client's son's concerns: The client's son may still feel responsible for their parent's well- being, even with reassurance from the nurse.
Choice B rationale:
Empathetic and validates the client's son's feelings: It directly acknowledges the client's son's conflicting emotions and demonstrates understanding of their difficult situation.
Promotes self-reflection and exploration: It encourages the client's son to further express their feelings and explore their options, which can lead to greater clarity and self-awareness.
Facilitates decision-making: It helps the client's son to weigh their priorities and make a decision that aligns with their values and responsibilities, ultimately empowering them to take action.
Strengthens the therapeutic relationship: It demonstrates the nurse's ability to connect with the client's son on an emotional level, building trust and rapport.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Lock the doors to the unit and secure windows so they cannot be opened: While removing potential means of self-harm from the environment is a safety precaution, it is not the most immediate or effective intervention for a client actively experiencing suicidal ideation who has refused a safety contract. Locking doors and windows may increase anxiety and feelings of entrapment, potentially exacerbating the client's distress and hindering open communication. Additionally, it may not address underlying emotional and psychological factors contributing to the suicidal thoughts.
Choice B: Remove any objects from the client's environment that could be used for self-harm: Similar to Choice A, removing potential means can be a helpful safety measure but should not be the primary intervention in this situation. It is important to recognize that clients can find alternative means if they are determined to self-harm, and focusing solely on environmental control can detract from addressing the root of the suicidal crisis.
Choice C: Assign a staff member to stay with the client at times: This option prioritizes the client's safety and emotional well-being by providing constant support and supervision. A dedicated staff member can:
Monitor the client's behavior and emotional state closely, potentially identifying early warning signs of impending self-harm.
Provide open and non-judgmental support, allowing the client to express their thoughts and feelings freely without fear of being alone with their distress.
Engage in therapeutic communication, helping the client explore alternative coping mechanisms and develop safety plans for managing suicidal urges.
Alert other healthcare professionals if the client's condition deteriorates or if there is any immediate risk of self- harm.
Offer a sense of security and reassurance, knowing someone is constantly available to listen and intervene if needed.
Choice D: Provide the client with plastic eating utensils for meals: While this precaution may reduce the risk of self- harm at mealtimes, it addresses a very specific concern and does not address the broader issue of the client's suicidal ideation. It is also important to consider that plastic utensils may not be effective in preventing self-harm if the client is determined and resourceful.
Therefore, assigning a staff member to stay with the client at all times is the most appropriate and immediate action to prioritize the client's safety and emotional well-being in this situation. This approach fosters open communication, provides continuous support, and allows for early intervention if necessary. While environmental controls and risk assessments can be valuable complementary strategies, they should not overshadow the importance of close human connection and emotional support in crisis situations.
Correct Answer is C
Explanation
The correct answer(s) is/are:
C. Telling his parents that he doesn't want to talk about the suicide attempt.
Rationale:
Choice A: Planning to give his Xbox console to his best friend.
While giving away possessions can be a sign of hopelessness or detachment, in this case, it could also be interpreted as a gesture of closure or wanting to leave something meaningful behind for a loved one. It doesn't necessarily indicate ongoing suicidal intent.
Choice B: Stating that he wants to be with his peers more than with his parents.
This desire for social connection and autonomy is actually a positive sign in a post-suicidal attempt adolescent. It demonstrates a shift towards seeking support from outside the family unit and engaging with life beyond the immediate aftermath of the attempt.
Choice C: Telling his parents that he doesn't want to talk about the suicide attempt. This reluctance to discuss the attempt can be a red flag for several reasons:
Avoidance: Suppressing or avoiding thoughts and feelings related to the attempt can indicate a struggle to cope with the emotional trauma and potentially harboring lingering suicidal ideation.
Isolation: Withdrawing from open communication about the event can isolate the adolescent further, hindering the support system and potentially increasing the risk of reattempt.
Underlying distress: The inability to talk about the event may suggest unresolved emotional distress, unresolved conflicts, or ongoing stressors that could contribute to suicidal thoughts.
Therefore, while not wanting to talk doesn't definitively signify current suicidal intent, it warrants further exploration by the nurse to understand the underlying reasons behind the avoidance and ensure appropriate support and safety measures are in place.
Choice D: Preferring to eat his meals while watching TV.
This behavior is relatively neutral and doesn't directly suggest ongoing suicidal intent. While it might indicate depression or low motivation, it's not a specific indicator of suicide risk.
Conclusion:
Based on the rationale above, "telling his parents that he doesn't want to talk about the suicide attempt" (Choice C) is the most concerning behavior that suggests the adolescent might still have suicidal intent. It's crucial for the nurse to address this reluctance with empathy and understanding, exploring the underlying reasons and ensuring continued monitoring and support for the adolescent.
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