A nurse is assessing a client who recently experienced the loss of their partner.
Which of the following questions is the priority for the nurse to ask during this situational crisis?

"How do you think this event is affecting your life right now?".

"Are you having thoughts about harming yourself?".

"What do you usually do to cope with problems in your life?".

"Who do you talk to when you need help?".

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Asking how the event is affecting the client's life is important, but it is not the priority during a situational crisis. Safety and assessing for self-harm thoughts come first.

Choice B rationale:

This question is the priority because it assesses the client's safety and potential for self-harm, which is crucial during a crisis. If the client is having thoughts of self-harm, immediate intervention is required.

Choice C rationale:

Inquiring about the client's coping strategies is relevant, but it is not the primary concern when there is a potential risk of self-harm.

Choice D rationale:

Asking about who the client talks to for help is important but not the primary concern in a situation where self-harm may be a risk.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining consent from the client's family member is not the appropriate action in this scenario. The client has the right to make decisions about their own medical treatment, and the consent should come from the client themselves, not a family member.

Choice B rationale:

Informing the client that they have the legal right to refuse treatment at any time is the correct action. Informed consent is a fundamental principle of medical ethics, and the nurse should respect the client's autonomy and right to make decisions about their own healthcare.

Choice C rationale:

Requesting another nurse to review the procedure with the client may be helpful in providing additional information and support, but it does not address the client's right to refuse treatment. The primary responsibility is to ensure that the client is aware of their right to refuse.

Choice D rationale:

Encouraging the client to have the procedure goes against the principle of respecting the client's autonomy and right to make their own decisions about their healthcare. The nurse should not pressure the client into having the procedure.

A. Command hallucinations. B. Impaired memory. C. Inappropriate speech patterns. D. Rapid mood swings.

Correct Answer is A

Explanation

Choice A rationale:

Command hallucinations require immediate intervention by the nurse. Command hallucinations are auditory hallucinations in which the client hears voices instructing them to perform specific actions, often harmful or dangerous. These hallucinations can lead to the client engaging in harmful behaviors or self-harm. The nurse must address this symptom promptly to ensure the client's safety and well-being.

Choice B rationale:

Impaired memory is a common symptom in clients with delirium, but it does not require immediate intervention. While impaired memory can be distressing for the client, it is not an immediate safety concern. The nurse should address memory deficits as part of the overall care plan but prioritize more urgent issues like command hallucinations.

Choice C rationale:

Inappropriate speech patterns are also common in clients with delirium. While they may be concerning, they do not typically pose an immediate risk to the client's safety. The nurse should assess and address inappropriate speech patterns but prioritize the safety of the client, especially when command hallucinations are present.

Choice D rationale:

Rapid mood swings are a symptom of delirium but, like impaired memory and inappropriate speech patterns, do not require immediate intervention to the same extent as command hallucinations. The nurse should address mood swings as part of the overall care plan and ensure that the client's safety is not compromised due to their condition.

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A nurse is assessing a client who recently experienced the loss of their partner.Which of the following questions is the priority for the nurse to ask during this situational crisis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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A nurse is assessing a client who recently experienced the loss of their partner.
Which of the following questions is the priority for the nurse to ask during this situational crisis?