A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

A: "I'm glad you called, and I want to send an ambulance to help you."

B:"You must have been feeling pretty depressed to do that."

C:"Were you trying to kill yourself by taking an overdose?"

D:"Do you know how many pills were in the bottle?"

Answer and Explanation

The Correct Answer is A

Choice A Reason:
In a situation where a client has ingested a potentially lethal amount of medication, immediate medical intervention is crucial. Amitriptyline is a tricyclic antidepressant, and overdose can lead to life-threatening conditions such as cardiac arrhythmias, severe hypotension, and seizures. The nurse's priority is to ensure the safety of the client by sending an ambulance. This response also acknowledges the client's cry for help and initiates prompt action.

Choice B Reason:
While it's important to recognize the emotional state of the client, this response does not address the immediate medical emergency. The client's safety is the priority, and while their feelings are valid, this choice does not facilitate the urgent care needed.

Choice C Reason:
Asking if the client was trying to commit suicide can come across as judgmental and may close off communication. It's essential to maintain an open line of communication and focus on getting medical help rather than determining intent at this critical moment.

Choice D Reason:
Knowing the quantity of medication ingested can be useful information for medical professionals; however, it is not the most immediate concern in a crisis situation. The first response should be to ensure that medical help is on its way.

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Correct Answer is B

Explanation

Choice A reason:
Locking the doors and securing windows may prevent an escape attempt, but it does not address immediate risks within the client's environment. It can also make the client feel trapped or punished, which could exacerbate their distress.

Choice B reason:
Removing any objects that could be used for self-harm is a direct intervention that reduces immediate risk. It is a standard safety precaution in managing suicidal clients and helps create a safer environment while further assessments and interventions are planned.

Choice C reason:
Providing plastic eating utensils is a safety measure, but it is not as comprehensive as removing all objects that could be used for self-harm. This action should be part of a broader strategy to ensure safety.

Choice D reason:
Assigning a staff member to stay with the client can provide supervision and prevent an attempt at self-harm. However, it may not be feasible as a long-term solution and does not remove the means for self-harm.

A. "I check any room I enter because the enemy is still after me and could be hiding anywhere." B. "My child was born with a birth defect due to an exposure I had overseas." C. "I killed four enemy soldiers with my bare hands and saved my entire battalion." D. "In my dreams, all I can see are the wounded reaching out and trying to grab me."

Correct Answer is D

Explanation

Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.

Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.

Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.

Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.

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A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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