A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

"Have you been thinking about harming yourself?"

"Why do you feel like things will never work out?"

“You should try to focus on yourself for a change."

“Maybe an antidepressant will make you feel better."

Answer and Explanation

The Correct Answer is A

A.   This response directly addresses the potential for self-harm, which is a critical concern when a client expresses hopelessness. It is an open-ended question that invites the client to discuss their feelings and provides the nurse with information to assess the client's safety.
B.   Asking the client a why question may not be alright and this may make them to be guarded.
C.   This response may come off as dismissive and lacks empathy towards the client's feelings.
D.   Suggesting medication without further assessment is premature and may not address the root cause of the client's statement.

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Correct Answer is B

Explanation

A. While a client with anorexia nervosa may require close monitoring and support, expressing a fear of gaining weight does not necessarily indicate an immediate safety concern that requires an update to the plan of care.

B. Bipolar disorder can involve manic episodes characterized by impulsivity and risk-taking behaviors. Exhibiting poor impulse control indicates a potential safety concern that requires an update to the plan of care to ensure the client's safety and the safety of others.
C. Clang associations in speech are a symptom of disorganized thinking commonly seen in schizophrenia. While it may indicate a need for intervention, it does not necessarily require an immediate update to the plan of care for safety reasons.
D. Difficulty remembering names of family members is a symptom of Alzheimer's disease and may require ongoing support and management but does not present an immediate safety concern that requires an update to the plan of care.

A. Encourage the client to have the procedure. B. Obtain consent from the client's family member. C. Inform the client that they have the legal right to refuse treatment at any time. D. Request another nurse to review the procedure with the client.

Correct Answer is C

Explanation

A. Encouraging the client to have the procedure disregards their autonomy and right to refuse treatment.
B. Obtaining consent from a family member is not appropriate if the client is capable of making their own decisions.
C. Informing the client of their legal right to refuse treatment respects their autonomy and allows them to make an informed decision about their care.
D. Requesting another nurse to review the procedure may be helpful for clarification but does not address the client's right to refuse treatment.

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A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

Correct Answer is B

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Correct Answer is C

Explanation

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