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 D

Explanation

A. Speaking in rhyming sentences can be a manifestation of mania but may not necessarily require immediate reporting unless it escalates to disruptive or harmful behavior.
B. Making inappropriate sexual comments can indicate impulsivity and lack of social boundaries. It does not however precede managing the risk of hypoglycemia.
C. Poor hygiene, such as not bathing, is common in mania due to increased energy and decreased need for sleep, but it may not require immediate reporting unless it poses a significant risk to the client's health.
D. Decreased appetite and irregular eating patterns are common during mania due to increased activity levels. Eating twice in teh past is not sufficient to meet energy requirements and the client might be at risk of hypoglycemia.

A. Administer methadone hydrochloride. B. Monitor for orthostatic hypotension. C. Acidify the client's urine. D. Implement seizure precautions.

Correct Answer is D

Explanation

A. Methadone hydrochloride is not indicated for the management of alcohol intoxication or withdrawal. It is primarily used for opioid addiction treatment.
B. While monitoring for orthostatic hypotension is important in clients with alcohol use disorder, implementing seizure precautions is a higher priority because alcohol withdrawal can lead to
seizures.
C. Acidifying the client's urine is not indicated in the care of an intoxicated client with alcohol use disorder.
D. Implementing seizure precautions is essential in clients with alcohol use disorder who are at risk for alcohol withdrawal syndrome, which can include seizures as a potential complication.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

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