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 C

Explanation

A. Meeting one's own needs without manipulating others may be a desirable outcome but is not specific to the core deficits of autism spectrum disorder.

B. Acknowledging that delusions are not real is more relevant to psychotic disorders rather than autism spectrum disorder.
C. Initiating social interactions with caregivers is an appropriate outcome for individuals with autism spectrum disorder, as it reflects improved social communication skills and social engagement.
D. Individuals with autism spectrum disorder may have difficulty understanding and responding to peer pressure, so changing behavior as a result of peer pressure may not be a realistic or desirable outcome.

A. Place the client in a reclining chair. B. Put locks at top of doors. C. Encourage physical activity prior to bed time. D. Position the mattress on the floor. E. Install sensor devices on outside doors.

Correct Answer is ["B","C","D","E"]

Explanation

A. Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B. Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C. Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D. Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E. Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

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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 is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

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