A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

"You should have asked for help."

"Let's talk about how you were feeling."

"I think you are experiencing guilt."

"Everyone gets discouraged sometimes."

Answer and Explanation

The Correct Answer is B

A.   This response could come across as blaming or judgmental. It implies that the client made a mistake by not seeking help, which can exacerbate feelings of guilt or shame. It does not promote an open dialogue or supportive environment.
B.   This response demonstrates empathy and a willingness to understand the client's emotional state leading up to the suicide attempt. It encourages open communication about the client's feelings and experiences, which is crucial for assessment and intervention planning.
C.   This response suggests that the nurse is making assumptions about the client's emotions without allowing the client to express themselves fully. While guilt may be a common emotion after a suicide attempt, it's important for the nurse to first listen to the client's own description of their feelings.
D.   This response minimizes the seriousness of the client's experience and emotions. It may invalidate the client's feelings of distress or despair that led to the suicide attempt. Such a response does not acknowledge the gravity of the situation or provide the necessary support.

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Correct Answer is D

Explanation

A. Consuming alcohol close to bedtime can disrupt sleep patterns. While alcohol may initially induce drowsiness, it often leads to fragmented and poor-quality sleep later in the night. Therefore, advising the client to drink alcohol before bedtime is not recommended.
B. Taking long or late-afternoon naps can interfere with nighttime sleep patterns, especially for individuals experiencing insomnia or sleep disturbances related to depression. Napping can make it harder to fall asleep or stay asleep at night, thereby exacerbating sleep problems rather than improving them.
C. Eating a large or heavy meal just before bedtime can lead to discomfort, indigestion, and even heartburn, which can interfere with falling asleep and staying asleep. It's generally advisable to avoid heavy meals close to bedtime to promote better sleep quality.
D. Caffeine is a stimulant that can interfere with sleep. Consuming caffeinated beverages, especially in the afternoon or evening, can make it difficult for individuals with depression to fall asleep and can contribute to fragmented sleep. Limiting caffeine intake earlier in the day can help promote better sleep hygiene.

A. Allow the client to choose activities for the day. B. Redirect client behavior by initiating physical exercise. C. Encourage the client to spend time with others D. Be specific when explaining care to the client.

Correct Answer is D

Explanation

A. Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B. Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C. Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D. Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

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A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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