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?

"When you get better you will not feel this way."

"Are you thinking of hurting yourself?"

"What would your family do without you?"

"Why would you think a thing like that?"

Answer and Explanation

The Correct Answer is B

The correct answer is B. The nurse should assess the client's risk for suicide by asking directly about suicidal thoughts or plans. This is a priority intervention that can help prevent harm to the client and provide appropriate referrals for further evaluation and treatment.

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Correct Answer is D

Explanation

Choice A reason:

Allow the client's partner to translate. While the partner may be well-intentioned, using a family member or friend as an ad-hoc interpreter can compromise the confidentiality of the information and may not accurately convey the client's medical concerns.

Choice B reason:

Have the client's child translate. Relying on a child to translate sensitive medical information is inappropriate, as it may burden the child and may lead to potential misunderstandings or omissions in communication.

Choice C reason:

Ask a nursing student who speaks the same language as the client to translate. Although a nursing student who speaks the same language as the client may be able to assist, using a professional interpreter is the preferred option. Professional interpreters have specific training in medical terminology and communication, ensuring the most accurate and effective exchange of information.

Choice D reason:

Using a professional interpreter is essential in situations where the healthcare provider and the client do not speak the same language. It ensures accurate communication, maintains confidentiality, and prevents misunderstandings. In this scenario, the nurse should request an interpreter who is proficient in the client's language to assist with the admission process.

A. Instruct the client to cough every 4 hr. B. Encourage the client to ambulate to loosen secretions. C. Maintain the client in high-Fowler's position. D. Increase the client's intake of oral fluids.

Correct Answer is C

Explanation

The nurse should maintain the client in high-Fowler's position, which promotes lung expansion and reduces venous return to the heart.

This can help alleviate dyspnea and improve oxygenation in clients with heart failure.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is collecting data from a client who has heart failure. The nurse notes the client has crackles in the bases of the lungs, shortness of breath, and a respiratory rate of 24/min. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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