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 C
Explanation
A client who has moderate-stage Alzheimer's disease may experience confusion, memory loss, wandering, agitation, and impaired judgment. Placing this client closest to the nurse's station can facilitate close observation and intervention, as well as reduce environmental stimuli that may trigger anxiety or disorientation.
Correct Answer is D
Explanation
Cocaine is a stimulant that can cause paranoia, increased heart rate, and elevated blood pressure in high doses or during acute intoxication.
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