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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. This statement indicates that the client has abstained from alcohol while on haloperidol decanoate. This is a positive statement and shows compliance with recommendations, as alcohol can interact with medications and affect their effectiveness or cause adverse reactions. There is no immediate concern with this statement.
B. Haloperidol can increase sensitivity to sunlight (photosensitivity). Spending several hours outside gardening in the sun could potentially increase the risk of sunburn or other skin reactions due to photosensitivity. The nurse should address this statement by educating the client about the need to use sunscreen, wear protective clothing, and avoid prolonged sun exposure, especially during peak sunlight hours.
C. Regular monitoring of blood pressure is generally recommended for clients taking haloperidol, as it can occasionally cause hypotension (low blood pressure) as a side effect. Checking blood pressure once a week is a reasonable frequency, but the nurse should ensure that the client understands the signs and symptoms of hypotension and knows when to seek medical attention if blood pressure readings are abnormal.
D. Chewing sugar-free gum is generally not contraindicated while taking haloperidol. However, if the gum contains caffeine or other stimulants, it could potentially exacerbate certain side effects of the medication, such as tremors or restlessness. The nurse should inquire further about the type of gum being used and educate the client about potential interactions or side effects.
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.
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