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. "Why do you think your life is not worth it anymore?": Asking “why” can feel judgmental and may cause the client to withdraw rather than share openly. It directs the conversation toward justification rather than safety assessment, delaying the nurse’s responsibility to determine immediate suicide risk.
B. "You can trust me and tell me what you are thinking": While supportive, this statement is too vague and does not address the urgent need to assess suicidal intent. It does not guide the client toward providing specific information needed to evaluate the level of risk and plan for safety.
C. "I need to know what you mean by misery": This response explores the client’s feelings but does not directly address the expressed suicidal thoughts. Focusing on the term “misery” may allow critical details about planning or intent to go unassessed during a potentially dangerous moment.
D. “Do you have a plan to end your life?”: This is an appropriate and essential safety-focused response because it directly assesses the client’s level of suicidal intent and the presence of a plan. Determining whether a plan exists helps the nurse evaluate the immediacy of the risk and initiate protective interventions without delay.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. First image: The rhythm shows irregular beats with visible P waves before each QRS complex, which is more consistent with normal sinus rhythm with occasional premature beats, not atrial fibrillation.
B. Second image: The rhythm appears regular with consistent P waves preceding each QRS, indicating normal sinus rhythm. There are no signs of atrial fibrillation.
C. Third image: The rhythm is irregularly irregular with no discernible P waves and variable R-R intervals, which are hallmark features of atrial fibrillation. This rhythm increases the client’s risk for thromboembolism and requires careful monitoring and management.
Correct Answer is D
Explanation
A. Compensation: Compensation involves emphasizing a strength to make up for a perceived weakness or deficiency. Preparing a deceased partner’s favorite meals does not serve to offset a personal deficiency, so this is not the correct defense mechanism.
B. Dissociation: Dissociation is the temporary detachment from reality or identity to cope with stress or trauma. Cooking familiar meals does not indicate a detachment from reality; the client is fully aware of their actions and circumstances.
C. Rationalization: Rationalization involves creating logical explanations to justify unacceptable behaviors or feelings. Cooking meals for a deceased partner is not an attempt to justify behavior but a coping mechanism, so rationalization does not apply.
D. Denial: Denial is a defense mechanism in which a person refuses to accept reality or facts to avoid emotional pain. Continuing to cook meals for a deceased partner reflects the client’s difficulty accepting the loss, making denial the most appropriate identification of their behavior.
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