A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
"Who do you talk to when you feel overwhelmed?"
"Are you thinking about harming yourself?"
"Can we talk about how your partner's death has affected you?"
"What do you usually do to calm your thoughts?"
The Correct Answer is B
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Providing rest breaks between nursing care activities is essential to prevent fatigue and allow for recovery, as stroke patients often have reduced endurance and energy.
B. Notifying the provider of a systolic blood pressure higher than 180 mm Hg is crucial because hypertension can exacerbate brain injury following a stroke and increase the risk of hemorrhagic transformation.
C. Administering aspirin 650 mg every 6 hours for a headache is not recommended without a physician's order, especially post-stroke, as it can increase the risk of bleeding.
D. Keeping the client's head in a midline neutral position helps to promote venous drainage and decrease intracranial pressure, which is beneficial in the management of a stroke patient.
E. Monitoring the client's vital signs every 4 hours is important for detecting any changes in the patient's condition that may indicate complications or the need for medical intervention.
Correct Answer is B
Explanation
Choice A rationale:
Abdominal cramps are not typically associated with opioid intoxication. Choice B rationale:
Opioid intoxication can cause symptoms such as slowed or slurred speech, drowsiness, and altered mental status.
Choice C rationale:
Opioid intoxication often leads to bradycardia (slower heart rate), not tachycardia (faster heart rate).
Choice D rationale:
Diaphoresis (excessive sweating) is a symptom of opioid withdrawal, not intoxication.
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