A nurse is caring for a client whose child died from cancer. The client states, "It's hard to go on without him." Which of the following questions should the nurse ask the client first?
"What has helped you through difficult times in the past?"
"Has anyone in your family committed suicide?"
"Are you thinking about ending your life?"
"Is there anyone you would like involved in your care?"
The Correct Answer is C
A. "What has helped you through difficult times in the past?": Important but not the priority in a potential crisis.
B. "Has anyone in your family committed suicide?": Relevant but not the first question.
C. "Are you thinking about ending your life?": Directly assesses the client's safety and risk for suicide.
D. "Is there anyone you would like involved in your care?": Supports coping but is not urgent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A client upset about a change in routine does not present an immediate threat to their health.
B. Assistance with ADLs is important but not urgent compared to a possible adverse drug reaction.
C. A sore throat in a client taking clozapine may indicate agranulocytosis, a potentially life-threatening condition that requires immediate evaluation.
D. Mocking others is disruptive but not a priority over a potential medical emergency.
Correct Answer is ["B","C","D","G"]
Explanation
|
System |
Findings |
|
General |
Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me." |
|
Physical |
Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min |
|
Affect |
Client says, "Why don't you just leave me? I am of no use." |
Rationale
These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.
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