A nurse working at a crisis hotline call center receives a call from a client who states, "I cannot take it. My life is over." Which of the following is the priority response by the nurse?
"Are you thinking of harming yourself?"
"You made the right decision by calling the hotline."
"Tell me more about what is going on in your life."
"Is there anyone with you right now?"
The Correct Answer is A
A. "Are you thinking of harming yourself?": Directly assessing for suicidal ideation is the immediate priority when a caller expresses hopelessness or statements suggesting despair. Asking clearly and directly about self-harm does not increase suicide risk and allows the nurse to determine intent, plan, and urgency. Early identification of suicidal thoughts is essential.
B. "You made the right decision by calling the hotline.": Offering reassurance and support is therapeutic, but it does not immediately assess the level of suicide risk. While validation can build rapport, determining whether the client is at imminent risk of self-harm takes priority over supportive statements.
C. "Tell me more about what is going on in your life.": Encouraging the client to elaborate is helpful for understanding stressors and emotional context. However, when suicidal ideation is suspected, directly assessing for self-harm risk must occur first to determine immediate safety needs before exploring background details.
D. "Is there anyone with you right now?": Determining whether the client is alone is important in crisis management, particularly if suicide risk is confirmed. However, this question should follow direct assessment of suicidal intent so that the nurse understands the level of immediate danger before addressing environmental support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You can use an eyebrow pencil to fill in your eyebrows.": This statement provides practical, supportive guidance that empowers the client to manage visible effects of chemotherapy. Offering concrete strategies for coping with hair loss helps maintain self-esteem and promotes a sense of control during treatment.
B. "I lost my hair, too, when I went through chemotherapy.": Sharing personal experiences can sometimes foster connection, but it may shift focus away from the client’s feelings and minimize their individual emotional response. The priority is validating the client’s concerns rather than centering the nurse’s experiences.
C. "Before you know it, your hair will grow back.": While hair regrowth is expected after chemotherapy, this statement may unintentionally dismiss the client’s current distress. It does not address the emotional impact of hair loss in the present moment.
D. "You should focus on getting better.": This directive can be perceived as dismissive and minimizes the client’s emotional experience. It fails to acknowledge the psychosocial impact of chemotherapy side effects and does not offer supportive guidance.
Correct Answer is A
Explanation
A. "Wait 5 minutes between doses.": Sublingual nitroglycerin is taken to relieve acute angina episodes. The recommended protocol is to place one tablet under the tongue and, if pain persists, repeat every 5 minutes as needed, up to a maximum of three doses within 15 minutes. Waiting 5 minutes between doses allows the medication to work while monitoring for resolution of symptoms or adverse effects.
B. "Place 2 tablets under your tongue.": Only one tablet should be taken initially. Taking multiple tablets at once increases the risk of severe hypotension, headache, and dizziness. Proper dosing is critical to both effectiveness and safety.
C. "You can take up to 4 tablets in 20 minutes.": The maximum recommended is three tablets in 15 minutes, not four in 20 minutes. Exceeding this can cause significant hypotension and cardiovascular complications.
D. "Drink a full glass of water with the medication.": Sublingual nitroglycerin should not be swallowed or taken with water because it needs to dissolve under the tongue for rapid absorption into the bloodstream. Drinking water would reduce its effectiveness.
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