A client diagnosed with major depressive disorder tells the nurse that he and his family would be better off if he were gone. Which of the following is the nurse's priority response?
"Do you really think your family would be better off without you?"
"Tell me what is happening right now."
"When did you first start feeling this way?"
"Are you thinking of harming yourself?"
The Correct Answer is D
Choice A reason:
Asking the client if they really think their family would be better off without them could potentially validate the client's feelings of worthlessness and is not a priority when immediate safety concerns are present.
Choice B reason:
While it's important to understand the client's current situation, this open-ended question may not directly address the risk of harm the client might pose to themselves. It should follow after ensuring the client's safety.
Choice C reason:
Inquiring about the onset of these feelings is part of a thorough assessment but is not the most immediate concern when a client expresses thoughts that may indicate a risk of self-harm.
Choice D reason:
This direct question addresses the immediate safety concern and is the priority response when a client indicates they may be a danger to themselves. It is essential to assess for suicidal ideation directly to take appropriate steps to ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason:
Eating foods high in tyramine is not a risk factor for lithium toxicity. Tyramine is associated with dietary restrictions in patients taking monoamine oxidase inhibitors, not lithium.
Choice B reason:
Engaging in activities that cause excessive sweating, such as running 4 miles outdoors every afternoon, can lead to dehydration. Dehydration is a significant risk factor for lithium toxicity because it can increase lithium levels in the blood, potentially leading to toxicity.
Choice C reason:
Drinking 2 liters of liquids daily is generally recommended for hydration and is not a risk factor for lithium toxicity. Adequate hydration can help prevent lithium toxicity by ensuring that lithium is properly excreted through the kidneys.
Choice D reason:
Eating 2 to 3 grams of sodium-containing foods daily is within normal dietary intake ranges and is not a risk factor for lithium toxicity. Maintaining a consistent sodium intake is important when taking lithium, as low sodium levels can lead to increased lithium retention and potential toxicity.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today