A client states, "My life has no meaning right now." Which of the following responses should the nurse make?
Have you been thinking about harming yourself?
How long have you been feeling this way?
Tell me what is going on with you right now.
Do you really think your life has no purpose?
The Correct Answer is C
Choice A reason: Asking the client if they have been thinking about harming themselves is not the best response, as it may sound accusatory or judgmental. It may also make the client defensive or reluctant to share their feelings. The nurse should assess the client's suicide risk later, after establishing rapport and trust.
Choice B reason: Asking the client how long they have been feeling this way is not the most appropriate response, as it may imply that the nurse is more interested in the duration of the problem than the client's current situation. It may also suggest that the nurse expects the client to have a clear timeline of their feelings, which may not be the case.
Choice C reason: Telling the client to share what is going on with them right now is the best response, as it shows empathy and genuine interest in the client's perspective. It also invites the client to express their thoughts and emotions, and helps the nurse identify the factors that contribute to the client's sense of meaninglessness.
Choice D reason: Asking the client if they really think their life has no purpose is not a helpful response, as it may sound dismissive or sarcastic. It may also make the client feel invalidated or misunderstood, and reinforce their negative beliefs. The nurse should avoid challenging the client's statements, and instead explore the reasons behind them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Oliguria is not a condition that a nurse should expect in a client who has hypoglycemia. Oliguria is a reduced urine output, typically defined as less than 0.5 ml/kg/hour in an adult³. Oliguria can be a sign of dehydration, kidney failure, or urinary obstruction, but it is not related to low blood sugar levels.
Choice B reason: Diplopia is not a condition that a nurse should expect in a client who has hypoglycemia. Diplopia is a double vision, or seeing two images of a single object. Diplopia can be caused by various eye problems, such as strabismus, cataracts, or nerve damage, but it is not a common symptom of low blood sugar levels.
Choice C reason: Hypoglycemia is not a condition that a nurse should expect in a client who has hypoglycemia. Hypoglycemia is the condition itself, not a symptom. Hypoglycemia is a low blood sugar level, usually below 70 mg/dl. Hypoglycemia can result from taking too much insulin or other diabetes medications, skipping or delaying meals, exercising more than usual, or drinking alcohol.
Choice D reason: Dizziness is a condition that a nurse should expect in a client who has hypoglycemia. Dizziness is a feeling of lightheadedness, faintness, or unsteadiness. Dizziness can occur when the brain does not receive enough glucose, which is its main energy source. Dizziness can also be accompanied by other symptoms of hypoglycemia, such as confusion, hunger, sweating, shakiness, or weakness.
Correct Answer is ["B","C","E"]
Explanation
Choice A reason: Using seasonings to enhance the flavor of foods is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as some seasonings may be too spicy, salty, or acidic for the client. The nurse should advise the client to avoid foods that are greasy, fried, or have strong odors, and to choose bland, soft, or liquid foods that are easy to digest.
Choice B reason: Providing sips of room temperature ginger ale between meals is an intervention that the nurse should initiate. This can help to settle the stomach and reduce the nausea and vomiting. Ginger has antiemetic properties that can inhibit the serotonin receptors in the gastrointestinal tract. The nurse should also encourage the client to drink plenty of fluids to prevent dehydration.
Choice C reason: Maintaining the head of the client's bed in an elevated position after eating is an intervention that the nurse should initiate. This can help to prevent the reflux of gastric contents and reduce the nausea and vomiting. The nurse should also instruct the client to eat small, frequent meals, and to avoid lying down for at least an hour after eating.
Choice D reason: Offering 120 ml (4 oz.) of cold 2% milk as a meal replacement is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as milk and dairy products may be difficult to digest and may increase the production of mucus. The nurse should suggest other sources of protein and calcium, such as soy milk, yogurt, or cheese.
Choice E reason: Assisting the client in using guided imagery is an intervention that the nurse should initiate. This can help to reduce the nausea and vomiting, as well as the anxiety and stress associated with chemotherapy. Guided imagery is a relaxation technique that involves creating positive mental images that can distract the client from the unpleasant sensations and feelings. The nurse should help the client to choose an image that is soothing and comforting, and to focus on the sensory details of the image.
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