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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A."You've been feeling that your life has no meaning."This response reflects active listening and acknowledges the client's emotions. Itreflects the client's feelings and encourages them to express more about their emotions and thoughts. It shows empathy and understanding, which can help build trust and rapport.
B. "You have a great deal to live for" may seem dismissive and does not address the client's current feelings of worthlessness.
C. "It's not unusual for depressed people to feel that way" can come across as minimizing the client's unique experience and does not provide support or encourage further discussion.
D. "Why do you feel you are worthless?" might make the client feel defensive or overwhelmed, and it does not offer the same level of empathy and support as reflecting their feelings would.
Correct Answer is B
Explanation
A. "Why are you feeling so down?"
This response could come across as confrontational or invasive, potentially making the client feel uncomfortable. The client has already expressed their desire not to talk at the moment, so pushing for an explanation may not be well-received.
B. "I’ll just sit here with you for a few minutes then."
Explanation:
This response shows empathy and support without pushing the client to talk or sharing personal experiences. It respects the client's desire for space and acknowledges their emotions without being intrusive. It provides a calming and non-intrusive presence, giving the client the option to open up if and when they are ready.
C. "I understand. I've felt like that before, too."
While sharing personal experiences can sometimes be helpful, in this context, it might inadvertently shift the focus from the client's emotions to the nurse's experiences. It's important to keep the focus on the client and their feelings.
D. "It might help you feel better if you talk about it."
Suggesting that talking might help is well-intentioned, but it might pressure the client into discussing their feelings when they have clearly stated their preference not to at that moment. The client's autonomy and comfort should be respected.
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