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?"
"Is there anyone you would like involved in your care?"
"Has anyone in your family committed suicide?"
"Are you thinking about ending your life?" .
The Correct Answer is D
Choice A rationale:
Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.
Choice B rationale:
Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.
Choice C rationale:
While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.
Choice D rationale:
(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
"Uneven shoulder and pelvic heights." This is the correct answer. Uneven shoulder and pelvic heights, along with an asymmetrical appearance of the spine when viewed from the back, are clinical manifestations of scoliosis. Scoliosis is a sideways curvature of the spine that often develops during the growth spurt before puberty. Screening for scoliosis typically involves assessing the alignment of the spine and looking for these asymmetries.
Choice B rationale:
Exaggerated curvature of the sacrum is not a typical sign of scoliosis. Scoliosis primarily affects the upper back and can cause a side-to-side curvature of the spine, not the sacrum.
Choice C rationale:
Limited range-of-motion of the hips is not a specific indicator of scoliosis. Restricted hip movement might suggest other musculoskeletal issues but is not directly related to scoliosis.
Choice D rationale:
Mild pain in the hip region is not a characteristic symptom of scoliosis. While scoliosis can cause discomfort, it typically manifests as back pain, not specifically in the hip region. Pain symptoms can vary widely among individuals and might not be present in all cases of scoliosis.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Making decisions about health care on clients' behalf without their involvement violates the principle of patient autonomy. Patients have the right to be actively involved in decisions about their own care and treatment plans. Encouraging shared decision-making and respecting patients' choices are essential aspects of nursing advocacy.
Choice B rationale:
Promoting health care access is a fundamental aspect of advocacy in client care. Nurses should advocate for their patients' access to necessary healthcare services, treatments, and resources. This includes ensuring that patients have access to appropriate medical facilities, specialists, medications, and therapies. Advocating for health care access helps patients receive timely and appropriate care, improving their overall health outcomes.
Choice C rationale:
Encouraging clients to seek further information from the provider is crucial for informed decision-making. Providing patients with accurate and relevant information enables them to make educated choices about their health. Nurses can facilitate this process by clarifying medical information, explaining treatment options, and addressing patients' concerns. Informed patients are better equipped to actively participate in their care and advocate for their own needs.
Choice D rationale:
Addressing client needs when providing resources is an essential aspect of nursing advocacy. Nurses should assess their patients' individual needs and collaborate with other healthcare professionals to provide appropriate resources and support. This can include coordinating social services, arranging for home healthcare, or connecting patients with support groups. Meeting clients' needs ensures that they receive comprehensive care, promoting their overall well-being.
Choice E rationale:
Honoring family requests to withhold medical information can be ethically challenging. While family members play a significant role in a patient's life, confidentiality and patient autonomy must be respected. In most cases, healthcare providers should prioritize communicating directly with the patient, respecting their right to make decisions about their own health information. Exceptions may arise in situations involving legal guardianship or when patients are unable to communicate their preferences. However, the default approach should be to involve the patient directly in decisions about their healthcare information.
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