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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?"

Answer and Explanation

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.

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Correct Answer is ["A","C"]

Explanation

A. Caffeine is a stimulant and can interfere with sleep, especially if consumed in the afternoon or evening. It can lead to difficulty falling asleep and disrupt the sleep cycle.
B. While heavy meals close to bedtime can cause discomfort or indigestion, a light evening meal generally does not significantly interfere with sleep for most individuals.
C. The use of electronic devices, particularly before bedtime, can interfere with sleep due to the blue light emitted by screens. This light can suppress the production of melatonin, a hormone that helps regulate sleep.
D. Regular exercise generally promotes better sleep. However, vigorous exercise close to bedtime may interfere with sleep due to the increase in adrenaline, but this is not always the case.
E. The medications taken by the individual do not interfere with sleep.

A. Place the client's hands in warm water. B. Administer a benzodiazepine. C. Place an ice pack on the client's perineum. D. Perform a fundal massage.

Correct Answer is A

Explanation

A. Place the client's hands in warm water: This action can stimulate the client’s natural reflex to urinate. The warm water helps relax the muscles involved in urination.

B. Administer a benzodiazepine: Incorrect. Benzodiazepines are not indicated for difficulty urinating postpartum and can cause unnecessary sedation.

C. Place an ice pack on the client's perineum: Incorrect. An ice pack is typically used to reduce swelling or discomfort, but it is not a primary intervention for urinary retention.

D. Perform a fundal massage: Incorrect. Fundal massage is performed to assess uterine tone, not for urinary retention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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