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:
Identifying possible precipitating factors related to the infections is the first step in addressing the issue of increased catheter infections. Understanding the potential causes, such as poor catheter insertion techniques, inadequate hygiene practices, or contaminated equipment, can help the nurse pinpoint the areas that need improvement. By identifying these factors, the nurse can implement targeted interventions to prevent future infections.
Choice B rationale:
Meeting with providers to discuss measures to decrease infections is a valid step, but it should come after identifying the specific factors contributing to the infections. Without a clear understanding of the root causes, the discussion with providers may lack focus and may not lead to effective solutions.
Choice C rationale:
Revising the current policy for catheter care can be considered after identifying the precipitating factors. Policy revision should be based on evidence-based practices and a thorough understanding of the issues contributing to the infections. Simply revising the policy without addressing the underlying causes may not lead to significant improvements.
Choice D rationale:
Scheduling nursing staff training for infection control procedures is an important step in preventing infections, but it should also follow the identification of specific issues related to the catheter infections. Training programs can be tailored to address the identified problems and provide targeted education to the staff members involved.
Correct Answer is C
Explanation
Choice A rationale:
Weight gain is a common side effect of many antipsychotic medications, including haloperidol. While it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use.
Choice B rationale:
Dry mouth is a common anticholinergic side effect of antipsychotic medications like haloperidol. Although it is important to monitor for this adverse effect, it is not specifically related to the extrapyramidal symptoms, such as parkinsonism, associated with haloperidol use.
Choice C rationale:
This is the correct answer. Shuffling gait, or parkinsonism, is an extrapyramidal symptom associated with the use of antipsychotic medications like haloperidol. It is a movement disorder characterized by a shuffling walk, rigidity, and tremors. Recognizing and reporting this symptom promptly is crucial, as it may indicate the development of a serious neurological condition called tardive dyskinesia.
Choice D rationale:
Sedation is a common side effect of haloperidol and other antipsychotic medications. While it is important to monitor for sedation, it is not specifically related to the extrapyramidal symptoms associated with haloperidol use, as described in choice C.
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