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
Choice A reason: Asking why the client thinks their life is not worth it is too broad and may come across as challenging or judgmental. It does not directly assess the client’s risk of harm and may not provide the nurse with the critical information needed to ensure safety.
Choice B reason: Telling the client they can trust the nurse is supportive, but it is vague and does not directly address the immediate risk of suicide. While building trust is important, the priority is to assess the client’s intent and plan.
Choice C reason: Asking what the client means by misery explores feelings but does not assess the immediate risk of suicide. While understanding the client’s emotional state is valuable, the nurse must first determine if the client has a plan, which indicates the level of risk.
Choice D reason: Asking if the client has a plan to end their life is the most appropriate response because it directly assesses suicide risk. The presence of a plan indicates a higher level of danger and guides the nurse in determining the urgency of interventions. This is the correct answer because it prioritizes safety and risk assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A positive Babinski reflex beyond 12 to 18 months is abnormal and indicates possible neurological dysfunction. At 15 months, the reflex should have disappeared as the nervous system matures. Persistence of this reflex suggests an upper motor neuron lesion or developmental delay, making it a reportable finding.
Choice B reason: The Moro reflex normally disappears by 4 months of age. Its absence at 15 months is expected and does not indicate abnormality.
Choice C reason: Referring to self by name is an appropriate developmental milestone for toddlers around 15 months. It reflects normal language and self-awareness development.
Choice D reason: Pointing to common objects when asked is a normal developmental milestone at this age, showing receptive language and cognitive development.
Correct Answer is C
Explanation
Choice A reason: Bronchodilators are used for conditions such as asthma or COPD to relieve bronchospasm. They are not routinely indicated for end-of-life dyspnea unless the client has a specific underlying respiratory condition. This option is incorrect because it does not address typical palliative care measures.
Choice B reason: Placing the client in Trendelenburg position (head lower than feet) worsens breathing difficulty by increasing pressure on the diaphragm and promoting aspiration risk. This option is incorrect because it would exacerbate respiratory distress.
Choice C reason: Using a fan to increase air circulation is a simple, non-invasive, and effective intervention for relieving dyspnea at the end of life. The sensation of moving air across the face can reduce the perception of breathlessness and improve comfort. This is the correct answer because it aligns with evidence-based palliative care practices.
Choice D reason: Decreasing oral fluid intake does not relieve dyspnea. While fluid restriction may be used in cases of fluid overload, it is not a direct intervention for easing breathing difficulty in end-of-life care. This option is incorrect because it does not address the client’s immediate symptom.
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