A nurse is caring for a client who has major depressive disorder.
The client tells the nurse, "I should be dead.
I have been a failure.”. Which of the following responses should the nurse make?

"You are feeling like a failure.”.

"I see many positive things about you.”.

"You're not the only client who feels this way.”.

"How can you feel that way when you have so much to live for?"

Answer and Explanation

The Correct Answer is A

Choice A rationale

Reflecting the client's feeling back to them, such as "You are feeling like a failure," acknowledges their emotional state without judgment or dismissal. This therapeutic communication technique validates the client's feelings and encourages further exploration of their thoughts and emotions.

Choice B rationale

While intended to be positive, stating "I see many positive things about you" can minimize the client's current feelings and may not address the underlying reasons for their negative self-perception. It can also sound dismissive of their distress.

Choice C rationale

Saying "You're not the only client who feels this way" can minimize the client's individual experience and may make them feel that their feelings are not unique or important. It does not directly address their specific statement of wanting to be dead.

Choice D rationale

Asking "How can you feel that way when you have so much to live for?" invalidates the client's current feelings and can make them feel misunderstood or defensive. It does not address the depth of their despair and suicidal ideation.

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Correct Answer is ["A","B","C"]

Explanation

Choice A rationale: Pupils

Dilated pupils are a common sign of stimulant intoxication, particularly with substances like methamphetamine. Given that the client recently injected an unknown substance, pupil dilation could indicate acute intoxication and require urgent evaluation to prevent potential overdose or complications.

Choice B rationale: Heart rate

A heart rate of 121–124/min is significantly elevated, suggesting tachycardia, which can be related to stimulant use (such as methamphetamine) or withdrawal effects. High heart rates, especially in the context of withdrawal, can increase the risk of arrhythmias or cardiac complications, requiring close monitoring and intervention.

Choice C rationale: Orientation

The client was oriented only to person upon admission, which suggests altered mental status. Substance intoxication or withdrawal can impair cognitive function, decision-making, and awareness, increasing the risk for agitation, confusion, or more severe withdrawal symptoms such as hallucinations or seizures.

Choice D rationale: Respiratory rate

A respiratory rate of 20/min falls within the normal range (typically 12–20 breaths per minute) and does not indicate immediate distress requiring escalation of care.

Choice E rationale: Medical history

While knowing the client’s medical history is important for long-term care planning, it does not require immediate reporting unless the client has a history of conditions that could complicate withdrawal.

Choice F rationale: Oxygen saturation

An oxygen saturation of 98% on room air is within normal limits, meaning oxygenation is adequate. There is no immediate concern requiring intervention based on this finding.

A. "Who do you talk to when you are upset?" B. "Do you have medical insurance?" C. "When did you last have a mammogram?" D. "How old were you when you started your menses?"

Correct Answer is A

Explanation

Choice A rationale

"Who do you talk to when you are upset?" explores the client's social support system, which is a critical component of their psychosocial status. Social support can buffer stress, provide emotional comfort, and contribute to overall well-being. Understanding who the client relies on for support helps assess their coping mechanisms and social connectedness.

Choice B rationale

"Do you have medical insurance?" pertains to the client's access to healthcare resources and socioeconomic status. While these factors can influence overall well-being, they are not direct indicators of the client's psychosocial status, which focuses more on their mental, emotional, and social functioning.

Choice C rationale

"When did you last have a mammogram?" is a question related to the client's physical health and preventive care practices, specifically relevant for female clients. It does not directly assess their psychosocial status, which encompasses their emotional state, social interactions, and coping abilities.

Choice D rationale

"How old were you when you started your menses?" is a question about the client's sexual and reproductive health history, relevant for female clients. While significant life events can indirectly impact psychosocial well-being, this specific question does not directly assess their current emotional state, social relationships, or coping mechanisms.

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A nurse is caring for a client who has major depressive disorder.The client tells the nurse, "I should be dead.I have been a failure.”. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

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Correct Answer is A

Explanation

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A nurse is caring for a client who has major depressive disorder.
The client tells the nurse, "I should be dead.
I have been a failure.”. Which of the following responses should the nurse make?