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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Urine specific gravity is the measurement of the concentration of solutes in urine and is an important indicator of the client's hydration status and kidney function. A specific gravity of 1.035 is relatively high, suggesting concentrated urine. High urine specific gravity can be a sign of dehydration or other kidney-related issues.
Reporting this finding to the provider is crucial because it could indicate potential problems with the client's fluid balance and kidney function. The provider may need to assess further, conduct additional tests, or initiate appropriate interventions to address the client's hydration and renal status.
Choice B reason:
Prealbumin: A prealbumin level of 25 mg/dL is within the normal range (usually 15-35 mg/dL) and may not require immediate reporting to the provider. Prealbumin is used to assess nutritional status, and this result suggests that the client's nutritional status is within the normal range.
Choice C reason:
Temperature: The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. Unless there are specific signs or symptoms of fever or infection, reporting the temperature is not necessary based on the given data.
Choice D reason
Bowel sounds: The provided information does not include any data about the client's bowel sounds, and there are no indications of gastrointestinal issues or abnormalities. Bowel sounds may not be relevant to report unless there are specific symptoms or signs of GI disturbances.
Correct Answer is C
Explanation
The correct answer is C. The risk manager.
Rationale: The risk manager is responsible for identifying and managing potential or actual sources of harm or loss in a healthcare organization. The risk manager would be interested in analyzing the data on zolpidem use and fall rate, implementing preventive measures, and reporting adverse events to regulatory agencies if needed. The surgeon may not be directly involved in prescribing zolpidem or monitoring its effects on postoperative clients. The case manager may not have access to or authority over medication administration policies or practices. The pharmacist may be able to provide information on zolpidem's pharmacokinetics and pharmacodynamics, but may not be able to address the organizational factors that contribute to fall risk.
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