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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. This statement suggests a potential for victim-blaming or placing responsibility on the adolescent for the assault. It does not reflect a positive support system because it may contribute to feelings of guilt and shame in the adolescent. Victims of sexual assault should not be made to feel responsible for the actions of the perpetrator.
B. While encouraging the adolescent to focus on the future can be positive, solely focusing on the future without acknowledging or processing the trauma of the assault may invalidate the adolescent's current feelings and experiences. A supportive approach involves acknowledging and validating the adolescent's emotions and experiences, both past and present.
C. This statement may come from a place of concern for the adolescent's safety and well-being, which is understandable. However, it can also indicate a lack of trust or an overprotective stance that may not fully empower the adolescent to regain a sense of control over their life and decisions.
D. This statement demonstrates an understanding of common reactions and emotions experienced by individuals who have been sexually assaulted. Acknowledging that the adolescent may feel self-blame can be a way to open up discussions about these feelings and reassure the adolescent that they are not at fault. It shows empathy and readiness to support the adolescent emotionally.

A. Keep staff interactions with the client to a minimum. B. Provide range-of-motion exercises to all extremities every 2 hr. C. Request the provider renew the prescription in 24 hr. D. Document the client's behavior in the medical record every 1 hr.

Correct Answer is C

Explanation

A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A nurse is caring for an adolescent who was recently sexually assaulted. Which of the following statements by the adolescent's guardian represents the presence of a positive support system?

Correct Answer is D

Explanation

A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is caring for a client who has an anxiety disorder. The client transforms their anxiety into physical manifestations. The nurse should recognize that the client is exhibiting which of the following manifestations?

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?

A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)

A nurse is preparing to administer disulfiram 375 mg PO once daily. Available is disulfiram 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a group of clients in a pediatric clinic. Which of the following clients is at highest risk for physical abuse?