A nurse in a mental health clinic is caring for an older adult client who has depression and has stopped taking their medication. The client tells the nurse. "I want to die now that my partner is gone." Which of the following responses should the nurse make?
"Tell me more about your partner."
"Have you thought about harming yourself?"
"Why did you stop taking your medication?
"You should discuss these feelings with your provider."
The Correct Answer is B
A. "Tell me more about your partner.":
While understanding the client's feelings about their partner is important, the immediate concern is the client's statement expressing a desire to die. Therefore, focusing on the client's thoughts about self-harm (Option B) takes precedence in ensuring their safety.
B. "Have you thought about harming yourself?":
This response is appropriate because it directly addresses the client's statement expressing a desire to die. It opens a dialogue about the client's thoughts and intentions related to self-harm, allowing the nurse to assess the client's risk and initiate appropriate interventions.
C. "Why did you stop taking your medication?":
While understanding the reasons behind medication non-compliance is important, the immediate concern is the client's current statement indicating suicidal ideation. Exploring the client's medication adherence can be addressed after addressing the acute safety concern.
D. "You should discuss these feelings with your provider.":
This response might be seen as avoiding the client's immediate expression of distress. It is important for the nurse to directly assess the client's risk and initiate appropriate interventions rather than deferring the responsibility to another healthcare provider at this moment.
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Related Questions
Correct Answer is C
Explanation
A. "You shouldn't worry about the future so you can concentrate on getting well.":
This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.
B. "If you work hard on your physical therapy, you won't need to worry.":
While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.
C. "You're concerned about what will happen when you leave the hospital?":
This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.
D. "Why are you concerned even though everyone is here to help you?":
This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.
Correct Answer is A
Explanation
A. Prepare the client for surgery:
In emergency situations, if immediate intervention is required to save the client’s life or prevent significant harm, the principle of implied consent may apply. This means that if the client is unconscious and immediate treatment is necessary, healthcare providers may proceed with treatment under the assumption that the client would consent if able. However, this should be done in accordance with facility policies and legal guidelines.
B. Obtain consent from the surgeon:
The surgeon is not the appropriate person to obtain consent from in this situation. Informed consent should ideally come from the client or a legal surrogate decision-maker, depending on the circumstances. Surgeons are responsible for discussing the procedure with the patient or their authorized representative before surgery, but obtaining consent is not the nurse's role.
C. Contact the facility's ethics committee for guidance:
While the ethics committee may provide guidance in complex ethical situations, the immediate concern in this emergency situation is to address the client's life-threatening condition. The nurse should prioritize actions that ensure the client receives timely and necessary medical care.
D. Keep the client stable until a family member arrives to give consent:
While obtaining consent from a family member is ideal, waiting for consent can delay critical and time-sensitive interventions. In emergency situations, the priority is to provide necessary medical care promptly to stabilize the client. If there is no one available to give consent immediately, healthcare providers may proceed with necessary interventions to preserve life and limb.
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