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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

Tell me the reasons you think your mother is depressed. This response shows empathy and active listening and invites the daughter to share more information about her mother's condition and behavior. The other responses are dismissive, inaccurate, or minimizing of the daughter's concern.

A. Stop the newly licensed nurse from administering the medication. B. Demonstrate how to verbally de-escalate the situation. C. Discuss the purpose of the medication with the client. D. Assess the need for physical restraints.

Correct Answer is B

Explanation

A. Stop the newly licensed nurse from administering the medication – While it is important to prevent the administration of medication against the client's will, the focus should initially be on de-escalation to address the client's refusal.

B. Demonstrate how to verbally de-escalate the situation – This is the most appropriate first action. De-escalation techniques can help calm the client and create a dialogue, potentially leading to a willingness to discuss the medication and its benefits.

C.discussing the medication's purpose, is also secondary to honoring the client's current refusal.

D.assessing the need for restraints, would be inappropriate without first stopping the medication administration and could escalate the situation. Therefore, the first and most critical action is to stop the medication administration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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