A nurse is caring for a client whose child died from cancer.
The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

"What has helped you through difficult times in the past?"

"Is there anyone you would like involved in your care?"

"Has anyone in your family committed suicide?"

"Are you thinking about ending your life?" .

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.

Choice B rationale:

Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.

Choice C rationale:

While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.

Choice D rationale:

(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.

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Correct Answer is A

Explanation

Question 1: The correct answer is Choice A - Stabilize the tube by taping it to the infant’s cheek.

Choice A Rationale: Stabilizing the nasogastric tube by taping it to the infant's cheek is crucial to prevent displacement, which could lead to complications such as misplacement into the respiratory tract or discomfort for the infant. Proper securing ensures the tube remains in the intended position, facilitating the safe and effective delivery of nutrients. This action aligns with standard nursing practices to promote patient safety and comfort during enteral feedings.

Choice B Rationale: Option B suggests positioning the infant in a supine position during feedings, which is incorrect. Placing the infant in a supine position increases the risk of aspiration due to the potential for reflux. Instead, the infant should be positioned upright or semi-upright with the head elevated to minimize the risk of regurgitation and aspiration.

Choice C Rationale: Aspiration of residual fluid from the infant's stomach and discarding it (Option C) is not recommended practice. Aspirated gastric contents should be measured and assessed for volume and color to evaluate gastrointestinal function and potential complications. Discarding the aspirate without evaluation could lead to the oversight of important clinical indicators or abnormalities in the infant's condition.

Choice D Rationale: Microwaving the infant's formula to a temperature of 41°C (105.8°F) (Option D) is an incorrect practice. Heating formula in a microwave can result in uneven temperature distribution, creating hot spots that may cause burns to the infant's delicate oral mucosa or esophagus. The preferred method for warming formula is to use a water bath or bottle warmer to achieve a consistent temperature close to body temperature (around 37°C or 98.6°F).

A. "The nurse will initiate acupuncture when I arrive at the unit." B. "My nurse can teach me biofeedback at the beginning of labor." C. "A transcutaneous electrical nerve stimulator will help with pelvic pressure." D. "I can use my ultrasound picture as a focal point during contractions." .

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Acupuncture is typically administered by a trained acupuncturist, not by the nurse. It is not commonly initiated upon arrival at the labor unit.

Choice B rationale: Biofeedback is a technique that usually requires prior training and practice; it is not typically taught for the first time at the beginning of labor.

Choice C rationale: Transcutaneous electrical nerve stimulation (TENS) can help manage back pain during labor but is not specifically used for pelvic pressure.

Choice D rationale: Using an ultrasound picture as a focal point during contractions is a common nonpharmacological pain management technique. Focal points help the client concentrate and manage pain through visualization and distraction.

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A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client whose child died from cancer.
The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?