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 D

Explanation

Choice A rationale:

Applying skin sealant on damp skin is not a correct technique when changing an ostomy appliance. Skin should be clean and thoroughly dry before applying any ostomy products. Moisture on the skin can interfere with the adhesion of the pouching system, leading to skin irritation and leakage.

Choice B rationale:

Removing the appliance before emptying the pouch is not the correct technique. Ostomy pouches are designed to be emptied without removing the entire appliance. Removing the pouch unnecessarily can cause discomfort to the client and may damage the surrounding skin. Regular emptying of the pouch while leaving the appliance in place is the appropriate practice.

Choice C rationale:

Ensuring that the skin is slightly damp for better adhesion of the pouch is not accurate. Ostomy pouches adhere best to clean, dry skin. Moisture on the skin can compromise the adhesive seal and lead to skin irritation. Therefore, the skin should be thoroughly dried before applying the ostomy pouching system.

Choice D rationale:

Tracing the size of the stoma onto the skin barrier is the correct technique when changing an ostomy appliance. The opening of the skin barrier (wafer) should match the size and shape of the stoma to ensure a proper fit. Tracing the stoma's size onto the barrier helps in cutting the opening to the appropriate size, preventing leakage and ensuring a secure fit around the stoma.

A. Instruct the client to lie supine with his knees flexed. B. Position the client in semi-Fowler's position. C. Cover the wound with a dry sterile dressing. D. Cover the wound with a transparent dressing.

Correct Answer is A

Explanation

Explanation: Evisceration is a surgical emergency that occurs when the abdominal contents protrude through the incision site. The nurse should instruct the client to lie supine with his knees flexed to reduce tension on the wound and prevent further damage.

The nurse should also cover the wound with a moist sterile dressing and notify the surgeon immediately. Positioning the client in semi-Fowler's position, covering the wound with a dry sterile dressing, or covering the wound with a transparent dressing are not appropriate actions for evisceration.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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?