A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

"Perhaps you should discuss this with your physician."

"Of course, you aren't going to die, at least not in the immediate future."

"I recommend you exercise daily and avoid smoking to decrease your risk."

"Tell me more about these fears of dying from a heart attack.".

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Deflecting the client's concerns to the physician dismisses the client's immediate need for emotional support and therapeutic communication.

It can hinder the development of a trusting nurse-client relationship.

The nurse is responsible for addressing the client's psychosocial needs, not solely deferring them to other healthcare professionals.

Choice B rationale:

Offering false reassurance is inappropriate and potentially harmful. It can erode trust if the client's fears are later realized.

It minimizes the client's legitimate concerns and invalidates their emotional experience.

Choice C rationale:

While lifestyle modifications are essential for managing coronary artery disease, providing unsolicited advice at this moment disregards the client's emotional distress.

It prioritizes physical health over the client's psychological well-being. It can be perceived as dismissive of the client's fears and concerns.

Choice D rationale:

Inviting the client to elaborate on their fears demonstrates active listening and encourages therapeutic communication. It validates the client's concerns and shows empathy for their emotional experience.

It provides an opportunity to assess the client's understanding of their condition and identify specific fears or misconceptions. It establishes a foundation for exploring coping mechanisms and providing appropriate support and education.

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Free Nursing Study Resources

Correct Answer is ["15"]

Explanation

Question: How many mL should the nurse administer per dose?

Step 1: 150 mg ÷ 50 mg

Step 2: 3 × 5 mL

Answer: 15 mL per dose.

A. Lock the doors to the unit and secure windows so they cannot be opened. B. Remove any objects from the client's environment that could be used for self-harm. C. Assign a staff member to stay with the client at all times. D. Provide the client with plastic eating utensils for meals.

Correct Answer is C

Explanation

Choice A: Lock the doors to the unit and secure windows so they cannot be opened: While removing potential means of self-harm from the environment is a safety precaution, it is not the most immediate or effective intervention for a client actively experiencing suicidal ideation who has refused a safety contract. Locking doors and windows may increase anxiety and feelings of entrapment, potentially exacerbating the client's distress and hindering open communication. Additionally, it may not address underlying emotional and psychological factors contributing to the suicidal thoughts.

Choice B: Remove any objects from the client's environment that could be used for self-harm: Similar to Choice A, removing potential means can be a helpful safety measure but should not be the primary intervention in this situation. It is important to recognize that clients can find alternative means if they are determined to self-harm, and focusing solely on environmental control can detract from addressing the root of the suicidal crisis.

Choice C: Assign a staff member to stay with the client at times: This option prioritizes the client's safety and emotional well-being by providing constant support and supervision. A dedicated staff member can:

Monitor the client's behavior and emotional state closely, potentially identifying early warning signs of impending self-harm.

Provide open and non-judgmental support, allowing the client to express their thoughts and feelings freely without fear of being alone with their distress.

Engage in therapeutic communication, helping the client explore alternative coping mechanisms and develop safety plans for managing suicidal urges.

Alert other healthcare professionals if the client's condition deteriorates or if there is any immediate risk of self- harm.

Offer a sense of security and reassurance, knowing someone is constantly available to listen and intervene if needed.

Choice D: Provide the client with plastic eating utensils for meals: While this precaution may reduce the risk of self- harm at mealtimes, it addresses a very specific concern and does not address the broader issue of the client's suicidal ideation. It is also important to consider that plastic utensils may not be effective in preventing self-harm if the client is determined and resourceful.

Therefore, assigning a staff member to stay with the client at all times is the most appropriate and immediate action to prioritize the client's safety and emotional well-being in this situation. This approach fosters open communication, provides continuous support, and allows for early intervention if necessary. While environmental controls and risk assessments can be valuable complementary strategies, they should not overshadow the importance of close human connection and emotional support in crisis situations.

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A client who has coronary artery disease tells the nurse he is afraid of dying from a heart attack. Which of the following responses should the nurse make?

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer amantadine 150 mg PO every 12 hr. The available medication is amantadine 50 mg/5 mL syrup. How many mL should the nurse administer per dose?

Correct Answer is ["15"]

Explanation

A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?

Correct Answer is C

Explanation

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