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 A
Explanation
The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.
Correct Answer is D
Explanation
The client's guardian is the legal representative who can provide informed consent for the client who is incompetent. The nurse should ensure that the guardian understands the risks, benefits, and alternatives of the proposed treatment or procedure.
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