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 C
Explanation
Choice A reason: The client dressing her affected side first is not a finding that the nurse should report to the interprofessional care team, as it indicates that the client is following the proper technique for dressing after a stroke. Dressing the affected side first helps the client maintain range of motion and prevent contractures of the affected limbs.
Choice B reason: The client bearing weight on their arms when using crutches is not a finding that the nurse should report to the interprofessional care team, as it is a normal and expected way of using crutches. Bearing weight on the arms helps the client balance and support their body weight while walking with crutches.
Choice C reason: The client coughing when swallowing her medications is a finding that the nurse should report to the interprofessional care team, as it indicates that the client may have dysphagia, or difficulty swallowing, which is a common complication of stroke. Dysphagia can increase the risk of aspiration, pneumonia, dehydration, and malnutrition. The nurse should assess the client's swallowing ability and refer them to a speech-language pathologist for further evaluation and intervention.
Choice D reason: The client's caregiver filling a pill organizer weekly is not a finding that the nurse should report to the interprofessional care team, as it is a positive and helpful way of managing the client's medications. Filling a pill organizer weekly can help the client and the caregiver remember the medication names, doses, and schedules, and prevent medication errors or omissions.
Correct Answer is D
Explanation
Choice A reason: Determining potential funding sources for the program is an important action, but not the first one. The nurse should first assess the needs of the target population, such as the number of older adults who need the service, their nutritional status, their preferences, and their barriers to access food.
Choice B reason: Inquiring about the availability of volunteers is an important action, but not the first one. The nurse should first assess the needs of the target population, and then plan the resources and personnel needed to implement the program.
Choice C reason: Identifying alternative solutions to address concerns is an important action, but not the first one. The nurse should first assess the needs of the target population, and then identify the possible challenges and solutions to deliver the service effectively and efficiently.
Choice D reason: Performing a needs assessment is the first action that the nurse should take, as it provides the basis for planning, implementing, and evaluating the program. A needs assessment involves collecting and analyzing data about the health status, needs, and resources of the target population and the community. It helps to identify the gaps, priorities, and goals of the program.
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