The home health aide reports to the practical nurse that the client has been trying to give away possessions.
When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?
“Tell me more about how you’re feeling.”.
“You’re not thinking of killing yourself, are you?”
“Have you thought of therapy?”
“Let’s discuss some coping strategies.”.
The Correct Answer is A
Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While it’s important to understand the circumstances leading to the assault, this statement does not require immediate attention from the nurse. It’s more related to the incident itself rather than the patient’s current condition.
Choice B rationale
Expressing hatred towards others can be a sign of emotional distress, but it does not require immediate medical attention.
Choice C rationale
Tingling in the fingers can be a sign of reduced blood circulation, which could be a result of the restraints. This requires immediate attention to prevent further complications.
Choice D rationale
While it’s important to address legal threats, this statement does not require immediate medical attention.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Reviewing diagnostic test results is a crucial method for gathering data during the assessment phase of the nursing process. These results can provide valuable insights into the client’s health status and help to guide the planning and implementation of care.
Choice B rationale
Interviewing the client and significant others is another important method for data collection. This can help to gather information about the client’s symptoms, lifestyle, and personal history, which can all inform the care provided.
Choice C rationale
Performing a physical assessment is a key part of data collection in the nursing process. This involves examining the client’s physical condition and looking for any signs of illness or injury.
Choice D rationale
Interpreting the behaviors of the client is also a crucial part of data collection. This can provide insights into the client’s mental and emotional state, which can be particularly important in mental health nursing.
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