A client who is having suicidal thoughts tells the nurse, "It just does not seem worth it anymore. Why not end my misery?" Which of the following responses by the nurse is appropriate?
"Why do you think your life is not worth it anymore?"
"You can trust me and tell me what you are thinking."
"I need to know what you mean by misery."
"Do you have a plan to end your life?"
The Correct Answer is D
A. This response may come across as confrontational and could potentially shut down further communication. It's important to offer support and empathy rather than immediately probing with questions.
B. While saying, "You can trust me and tell me what you are thinking," may foster trust, it is too vague and does not focus on assessing the client’s level of suicidal ideation or intent. Effective responses should prioritize safety by exploring specific details about the client’s thoughts.
C. "I need to know what you mean by misery" focuses on understanding the client’s emotional state but does not address the immediate concern of suicidal thoughts. While exploring the client’s feelings is important, it is secondary to assessing imminent risk.
D. Asking, "Do you have a plan to end your life?" is appropriate because it directly assesses the client’s risk for suicide. Determining whether the client has a specific plan, the means to carry it out, and intent to act is essential for evaluating the severity of the situation and implementing safety measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: The recommended hepatitis vaccine series does not consist of four vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends a 3-dose series for most individuals, which includes doses at birth, 1-2 months, and 6-18 months.
Choice B Rationale: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through exposure to infectious blood, semen, and other body fluids. Transmission can occur through direct contact with blood or body fluids of an infected person, unprotected sex, sharing needles, or from mother to child at birth.
Choice C Rationale: While chronic hepatitis C has been associated with an increased risk of developing renal cell carcinoma, the evidence linking chronic hepatitis B with renal cell cancer is less clear. Some studies suggest a potential association, but it is not established as a common complication.
Choice D Rationale: Individuals with a history of hepatitis B or C are generally ineligible to donate blood. This is due to the risk of bloodborne transmission of these viruses. Even if the individual has recovered or been cured of hepatitis C, they are still barred from donating blood or plasma.
Correct Answer is A
Explanation
A. Hypotension occurs because hypermagnesemia causes vasodilation, which lowers blood pressure. Magnesium acts as a smooth muscle relaxant, decreasing vascular resistance and contributing to hypotension. This is a common clinical finding when magnesium levels exceed the normal range.
B. Tachycardia is not expected with hypermagnesemia. Elevated magnesium levels depress the heart's electrical activity, leading to bradycardia (slow heart rate) instead of tachycardia.
C. Muscle cramps are typically associated with hypomagnesemia, which increases neuromuscular excitability. In hypermagnesemia, neuromuscular function is suppressed, leading to muscle weakness rather than cramps.
D. Hyperreflexia is a symptom of hypomagnesemia, not hypermagnesemia. In hypermagnesemia, neuromuscular activity is depressed, resulting in diminished or absent deep tendon reflexes
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