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?
"What would your family do without you?”
"When you get better you will not feel this way.”
"Why would you think a thing like that?”
"Are you thinking of hurting yourself?”
The Correct Answer is D
Choice A rationale:
Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.
Choice B rationale:
Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.
Choice C rationale:
Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.
Choice D rationale:
This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D: "My partner will use condoms with spermicides.”
Choice A rationale:
"My partner and I will use petroleum jelly with latex condoms.” This statement is incorrect because petroleum jelly can degrade latex condoms, making them more likely to break. It’s important to use water-based or silicone-based lubricants with latex condoms to maintain their integrity and effectiveness.
Choice B rationale:
"My partner and I will both use a condom during intercourse.” Using two condoms at once, also known as ‘double-bagging’, is not recommended as it can increase the friction between the condoms and lead to breakage. Therefore, this statement does not indicate an understanding of proper condom use.
Choice C rationale:
"I will be able to remove my contraceptive sponge immediately after intercourse.” The contraceptive sponge should be left in place for at least 6 hours after intercourse to ensure effectiveness, but not more than 30 hours in total. Immediate removal does not provide the necessary time for the spermicide in the sponge to deactivate the sperm.
Choice D rationale:
"My partner will use condoms with spermicides.” This statement is correct. Condoms with spermicides provide an additional layer of contraceptive protection by combining the barrier method with a chemical that deactivates sperm. This indicates an understanding of the teaching on effective contraceptive practices.
Correct Answer is C
Explanation
Choice A rationale:
Enabling the airbag when the baby is in the front seat of the car is incorrect. Airbags can be dangerous for infants and young children, and it is recommended to keep them in the rear seat, preferably in a rear-facing car seat.
Choice B rationale:
Positioning the car seat's retainer clip at the level of the baby's belly button is incorrect. The retainer clip should be at armpit level to ensure proper positioning and safety.
Choice C rationale:
Keeping the baby rear-facing in the car seat until she is 2 years old is the correct understanding of car seat safety. This statement aligns with the American Academy of Pediatrics (AAP) recommendations, which suggest keeping infants rear-facing as long as possible, ideally until they reach the maximum height and weight limits of their car seat.
Choice D rationale:
Placing the baby in the car seat at a 90-degree angle is incorrect. The correct angle for a rear-facing car seat depends on the manufacturer's guidelines but typically ranges from 30 to 45 degrees. The 90-degree angle is not safe and can compromise the baby's airway.
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