A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

"Let's discuss what you feel embarrassed about."

"Lots of people feel ashamed to tell their secrets."

"You will feel better if you tell me what you did last night."

"You shouldn't feel embarrassed to talk to me."

Answer and Explanation

The Correct Answer is A

This response demonstrates empathy and respect for the client's feelings, and encourages the client to explore and express his or her emotions. It also allows the nurse to assess the client's situation and provide appropriate support and interventions.

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Correct Answer is D

Explanation

Cocaine is a stimulant that can cause paranoia, increased heart rate, and elevated blood pressure in high doses or during acute intoxication.

A. Implement continuous one-to-one observation. B. Encourage the client to participate in group therapy. C. Ask the client to sign a no-suicide contract. D. Establish a rapport to foster trust.

Correct Answer is A

Explanation

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

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A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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