A nurse is caring for a client who has depressive disorder. The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?
"Why would you think a thing like that?"
"What would your family do without you?"
"Are you thinking of hurting yourself?"
"When you get better you will not feel this way."
The Correct Answer is C
A. "Why would you think a thing like that?": This is incorrect. Asking “why” could make the client feel defensive or that their feelings are being dismissed, which can hinder further conversation. It is important to approach suicidal statements with sensitivity and direct concern.
B. "What would your family do without you?": This is incorrect. While this may seem like a caring response, it places responsibility on the client to think about their family, which may not be helpful if they are feeling overwhelmed by their own emotions. The focus should be on the client’s safety and well-being.
C. "Are you thinking of hurting yourself?": This is correct. It is essential to directly assess the client's safety when they express suicidal thoughts. Asking this question shows concern for the client’s immediate safety and opens the door for further discussion on their feelings and potential plans.
D. "When you get better you will not feel this way.": This is incorrect. This response may dismiss the client’s current feelings and suggests that their emotions are temporary, which could undermine the seriousness of their statements. It is important to validate the client's feelings and address their safety directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I can have a meal up to 2 hours before the procedure.": This is not correct. Clients are typically instructed to fast for at least 8 hours before an intravenous pyelogram to ensure clear imaging results and reduce the risk of complications from anesthesia or contrast media.
B. "I will feel a warming sensation after the injection of the dye contrast.": This is correct. It is common for clients to experience a warm sensation when the contrast dye is injected during the procedure.
C. "I do not need to sign a consent form before this procedure.": This is incorrect. A consent form is required before the procedure as it involves the use of contrast dye and potential risks, such as allergic reactions.
D. "I should limit my fluid intake for 2 days after the procedure.": This is not correct. After the procedure, clients are usually encouraged to drink plenty of fluids to help flush the contrast dye from the body and prevent potential kidney complications.
Correct Answer is C
Explanation
A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.
B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.
C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.
D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.
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