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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

B. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

C. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

D. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

A. The client is consuming 25% of their meals. B. The client coughs frequently while eating. C. The client's blood pressure is 142/94 mm Hg. D. The client leans to the left side while sitting.

Correct Answer is B

Explanation

A. The client is consuming 25% of their meals.

Poor nutritional intake can lead to complications over time, but it is not the most immediate concern compared to other options. This finding is important but not the highest priority.

B. The client coughs frequently while eating.

Frequent coughing while eating can indicate dysphagia (difficulty swallowing), which increases the risk of aspiration. Aspiration can lead to serious complications like aspiration pneumonia, which is life-threatening. This is the nurse’s priority finding because it poses an immediate risk to the client’s airway and respiratory status.

C. The client's blood pressure is 142/94 mm Hg.

The blood pressure is elevated, which is concerning, especially in a post-stroke client. However, it is not critically high and does not present an immediate threat compared to the risk of aspiration.

D. The client leans to the left side while sitting.

Leaning to the left side while sitting could indicate poor balance or proprioception, which increases the risk of falls. While important to address, it is not as immediately critical as the risk of aspiration.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is B

Explanation

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