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
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Correct Answer is D
Explanation
A low platelet count (thrombocytopenia) can indicate bleeding disorders, infections, or adverse effects of medications. Clonazepam can cause thrombocytopenia as a rare but serious side effect. The nurse should report this finding to the provider as it may indicate a need to discontinue or adjust the medication.
Correct Answer is D
Explanation
This team member can help the client find appropriate and affordable housing options, as well as connect them with community resources and support services. The other team members have different roles in the client's care, such as providing recreational activities, occupational skills, or specialized nursing interventions.
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