A client who has major depressive disorder states to 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?

"Are you thinking of harming yourself?"

"Do you really think your family would be better off without you?"

"When did you first start feeling this way?"

"Tell me what is happening right now."

Answer and Explanation

The Correct Answer is A

A. "Are you thinking of harming yourself?": Correct

This is the priority response because it directly addresses the client's statement about being better off gone, which raises concerns about potential suicidal thoughts. Asking this question allows the nurse to assess the client's risk of self-harm or suicide and take appropriate actions to ensure their safety.

B. "Do you really think your family would be better off without you?": Incorrect

While this response attempts to engage the client in a conversation, it doesn't directly address the immediate concern of suicidal thoughts. It's important to prioritize assessing the client's safety before exploring their feelings about their family's perspective.

C. "When did you first start feeling this way?": Incorrect

While understanding the client's history and the onset of their feelings is important, it's not the priority response in this situation. Assessing the client's risk of harm takes precedence over gathering historical information.

D. "Tell me what is happening right now.": Incorrect

This response doesn't directly address the client's statement about being better off gone and doesn't assess the immediate risk of self-harm or suicide. While understanding the client's current situation is valuable, safety concerns should be addressed first.

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Correct Answer is C

Explanation

A) "I haven't gotten my period yet, and all my friends have theirs."

While the concern about not having gotten her period yet is a valid one, it's a common experience during adolescence. Variability in the timing of puberty is normal, and addressing this concern might involve providing reassurance and education about the natural range of development.

B) "There's a big pimple on my face, and I worry that everyone will notice it."

While concerns about physical appearance are common during adolescence, they are less urgent in terms of emotional and psychological well-being. Addressing body image issues is important, but the statement about lack of social acceptance and reciprocal liking indicates potentially deeper emotional challenges.

C) "None of the kids at this school like me, and I don't like them either."

Explanation:

Adolescence is a time of significant emotional and social development. The statement about not being liked by other students and not liking them in return indicates potential social isolation and difficulties in forming positive relationships. Adolescents often seek social acceptance and peer relationships are crucial for their well-being and development.

D) "My parents treat me like a baby sometimes."

This statement suggests a common parent-adolescent dynamic where there might be conflicts about independence and autonomy. While these feelings are valid, they don't necessarily reflect a higher priority concern related to social isolation and peer relationships.

A. Tell me what is concerning you." B. "Your husband is making really good progress." C. "Did your husband say something to upset you?" D. "Crying helps us let things out and we feel better."

Correct Answer is A

Explanation

A. "Tell me what is concerning you."

This response is the most therapeutic option. It invites the spouse to share their concerns and feelings, showing empathy and active listening. It opens the door for effective communication and understanding the spouse's perspective.

B. "Your husband is making really good progress."

While this response provides information about the husband's progress, it doesn't directly address the spouse's concerns or feelings. The spouse's emotional state needs to be acknowledged and explored before discussing the husband's progress.

C. "Did your husband say something to upset you?"

This response makes an assumption that the husband said something to upset the spouse. It might come across as accusatory or dismissive of the spouse's feelings. It's important to give the spouse the opportunity to express their emotions in their own words.

D. "Crying helps us let things out and we feel better."

This response offers a general statement about crying, but it doesn't directly address the spouse's concerns or invite further conversation. While it's true that crying can be cathartic, the focus here should be on understanding the spouse's specific worries.

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A client who has major depressive disorder states to 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?

Nursing Test Bank

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