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?" .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The described cardiac rhythm with a wavy baseline, no distinguishable P waves, and an increased heart rate is consistent with atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and often rapid heart rate. This rhythm is characterized by the absence of distinct P waves on the ECG.
Choice B rationale:
Ventricular asystole is a flatline on the ECG, indicating the absence of electrical activity in the heart. It is a life-threatening arrhythmia and requires immediate intervention with cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) protocols.
Choice C rationale:
Second-degree heart block is characterized by intermittent failure of atrial electrical impulses to conduct to the ventricles. This results in occasional dropped beats and a varying heart rate. It is not consistent with the described ECG findings in the question.
Choice D rationale:
Sinus tachycardia is a regular, fast heart rate originating from the sinoatrial (SA) node. In sinus tachycardia, P waves are present, indicating that the electrical impulses originate in the SA node. The described ECG findings do not match the characteristics of sinus tachycardia.
Correct Answer is C
Explanation
The correct answer is choiceC. “Have your child drink a small glass of water after swallowing the medication.”
Choice A rationale:
Adding digoxin to a half-cup of juice is not recommended because it can affect the absorption of the medication.It is best to give digoxin on an empty stomach or with a small amount of food if necessary.
Choice B rationale:
Limiting potassium intake is incorrect.In fact, maintaining adequate potassium levels is important because low potassium levels can increase the risk of digoxin toxicity.
Choice C rationale:
Having the child drink a small glass of water after taking the medication helps ensure that the medication is swallowed completely and reduces the risk of esophageal irritation.
Choice D rationale:
Repeating the dose if the child vomits within 1 hour is not recommended. If a dose is vomited, it should not be repeated to avoid the risk of overdose.The next dose should be given at the regular scheduled time.
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