A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?
"You should try to focus on yourself for a change."
"Why do you feel like things will never work out?"
"Have you been thinking about harming yourself?"
"Maybe an antidepressant will make you feel better."
The Correct Answer is C
Choice A reason:
Telling a client to focus on themselves for a change may come across as dismissive and does not address the underlying feelings of hopelessness. It is important for the nurse to acknowledge the client's feelings and provide support rather than suggesting a shift in focus without understanding the root cause of their distress.
Choice B reason:
Asking the client why they feel like things will never work out can be a useful way to explore their thoughts and feelings. However, it may not be the most immediate concern if the client is experiencing severe hopelessness or suicidal ideation. The nurse should prioritize assessing the client's safety and risk of self-harm.
Choice C reason:
Asking if the client has been thinking about harming themselves is crucial in assessing their safety. Suicidal ideation is a serious concern, and it is important for the nurse to directly address this issue to determine if the client is at risk of self-harm. This response shows that the nurse is taking the client's feelings seriously and is concerned about their well-being.
Choice D reason:
Suggesting an antidepressant might make the client feel better can be helpful in the long term, but it does not address the immediate emotional distress the client is experiencing. Medication can be part of a treatment plan, but the nurse should first ensure the client's immediate safety and provide emotional support.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
When educating the client about their medication, the nurse should teach the client that there is a risk for hypertensive crisis due to ingestion of tyramine.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Choice A: Hypertensive Crisis
Reason: Selegiline is a monoamine oxidase inhibitor (MAOI), which can cause a hypertensive crisis if the client ingests foods high in tyramine. Tyramine is found in aged cheeses, smoked meats, and certain alcoholic beverages. When MAOIs inhibit the breakdown of tyramine, it can lead to a sudden and dangerous increase in blood pressure. Normal blood pressure ranges are less than 120/80 mmHg.
Choice B: Tardive Dyskinesia
Reason: Tardive dyskinesia is a movement disorder characterized by involuntary, repetitive body movements. It is typically associated with long-term use of antipsychotic medications, not with MAOIs like selegiline. Therefore, this condition is not relevant to the client’s current medication.
Choice C: Rhabdomyolysis
Reason: Rhabdomyolysis is a serious condition involving muscle breakdown and release of muscle fiber contents into the bloodstream, which can lead to kidney damage. It is not a known side effect of selegiline. This condition is more commonly associated with severe physical exertion, trauma, or certain medications like statins.
Choice D: Infection
Reason: Infection is not a direct risk associated with selegiline. While some medications can suppress the immune system and increase infection risk, selegiline does not have this effect. Therefore, this condition is not applicable to the client’s medication education.
Choice E: Nervous System Instability
Reason: Nervous system instability can refer to a range of symptoms including dizziness, confusion, or seizures. While selegiline can cause some central nervous system side effects, it is not typically associated with a broad category of nervous system instability. The primary concern with selegiline remains the risk of hypertensive crisis due to tyramine ingestion.
Correct Answer is ["A","D","E"]
Explanation
Choice A reason:
Clients with PTSD often hold persistent negative beliefs about themselves, which is a core symptom of the condition. These beliefs may include thoughts of being bad, unworthy, or responsible for the traumatic event. This negative self-perception can contribute to feelings of shame, guilt, and low self-esteem, which are common among individuals with PTSD.
Choice B reason:
Talking excessively is not typically associated with PTSD. While some individuals may talk more when they are anxious or trying to avoid certain thoughts, it is not a diagnostic criterion or a common finding in PTSD. Instead, individuals with PTSD may avoid talking about the traumatic event and may be withdrawn or socially isolated.
Choice C reason:
Blaming others for one's own mistakes is not a characteristic finding in PTSD. Individuals with PTSD may experience heightened irritability or anger, but this symptom does not specifically include blaming others for personal mistakes. It is more common for individuals with PTSD to have distorted perceptions of blame related to the traumatic event, often blaming themselves when it is not warranted.
Choice D reason:
Difficulty falling or staying asleep is a common symptom of PTSD. Sleep disturbances, including insomnia, nightmares, and restless sleep, are frequently reported by individuals with PTSD. These issues can be directly related to hyperarousal and intrusive thoughts or memories of the traumatic event.
Choice E reason:
Having difficulty concentrating on tasks is another symptom commonly seen in individuals with PTSD. This difficulty can be due to intrusive thoughts, hyperarousal, or general distress related to the traumatic event. It can affect various aspects of daily life, including work, school, and social interactions.
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