A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

"How are things going at your job?"

"Why do you think this is happening to you?"

"You must he feeling very frightened right now."

"Maybe you should think more positively."

Answer and Explanation

The Correct Answer is C

A. "How are things going at your job?" This response redirects the conversation rather than addressing the client's emotional state.
B. "Why do you think this is happening to you?" This question may come across as challenging or blaming, which is not therapeutic.
C. "You must be feeling very frightened right now." This response validates the client's emotions, showing empathy and encouraging further expression of feelings.
D. "Maybe you should think more positively." This dismisses the client's distress and does not provide therapeutic support.

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Correct Answer is D

Explanation

A. I will turn the car seat forward facing when my baby is 1 year old. This is incorrect because the American Academy of Pediatrics recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight limit specified by the car seat manufacturer.
B. I will place the retainer clip on my baby's upper abdomen. This is incorrect because the retainer clip should be positioned at armpit level to properly secure the straps and protect the baby in case of a collision.
C. I will position the shoulder harness straps 3 inches above my baby's shoulders. This is incorrect because for a rear-facing car seat, the shoulder harness straps should be positioned at or just below the infant’s shoulders, not above.
D. I will position my baby at a 45-degree angle in the car seat. This is correct because positioning the baby at a 45-degree angle helps maintain an open airway and prevents airway obstruction due to the head falling forward.

A. "Did anything in particular make you feel this way?" B. "Would you tell me more about the changes you see in your body?" C. "Do you ever think about harming yourself?" D. "How long have you had these feelings of uselessness?"

Correct Answer is C

Explanation

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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A nurse is speaking with a client during a counseling session who states, "I feel like I am sliding off a cliff." Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

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