A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?
"How have you dealt with stress in the past?"
"Are you thinking of harming yourself?"
"Let's talk more about what you are experiencing."
"Tell me what makes you feel stressed."
The Correct Answer is B
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.
Correct Answer is B
Explanation
A: Giving the client atropine 30 min before the procedure is a task that requires professional nursing knowledge and skill to assess the medication's necessity and potential effects, thus it cannot be delegated to an assistive personnel.
B: Assisting with ambulation is a task that can be safely delegated to an assistive personnel, as it does not require the professional judgment or skill of a nurse. The assistive personnel can help maintain the client's safety while walking after the procedure.
C: Witnessing a client's signature on the consent for the procedure is a legal responsibility and requires an understanding of the procedure's risks and benefits, which is beyond the scope of assistive personnel's responsibilities.
D: Checking the client's condition after the procedure involves assessment and interpretation of clinical data, which are responsibilities of the nurse and cannot be delegated to an assistive personnel.
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