A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

Communicate to the client that it is acceptable to cry.

Determine the client's stage of grief.

Encourage the client to express feelings openly,

Enable the client to obtain spiritual support.

Answer and Explanation

The Correct Answer is B

A.   While crying may be a normal expression of grief, determining the client’s stage of grief is more important for assessing the client’s emotional needs.
B.   Determining the client’s stage of grief is the first step to understanding the client's emotional state
and providing appropriate support.
C.   Encouraging expression is important, but first, understanding the client’s grief stage will guide the
intervention.
D.   Spiritual support is valuable, but first, understanding the client's emotional response is necessary before offering this type of assistance.

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Correct Answer is B

Explanation

A. Identifying positive qualities about oneself is important but is not the immediate priority in someone at risk for self-harm.
B. Contacting a staff member when the client feels she might hurt herself is the priority, as it directly addresses the risk of harm and safety.
C. Identifying a reachable goal for the future is important but secondary to addressing immediate safety concerns.
D. Identifying her position in the grief process can be helpful but does not address the most immediate concern, which is her safety

A. "The voices are part of your illness." B. "I know you hear the voices, but I do not." C. "How often do you hear the voices?" D. "What are the voices telling you?"

Correct Answer is B

Explanation

A. While the voices may be part of the illness, it is important to acknowledge the client’s experience
without dismissing it.
B. Acknowledging the client's experience ("I know you hear the voices, but I do not") is important in establishing rapport and validating their reality.
C. Asking how often the voices are heard can be useful, but acknowledging the client’s perception
should be the first priority.
D. Asking what the voices are telling the client may come later, after the client’s experience has been
acknowledged.

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A nurse is caring for a client who has major depressive disorder and has experienced a recent loss. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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