A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?
"How have you dealt with stress in the past?"
"Are you thinking of harming yourself?"
"Let's talk more about what you are experiencing."
"Tell me what makes you feel stressed."
The Correct Answer is B
The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Weigh the client every other day – Frequent weighing can increase the client’s focus on weight, potentially adding stress and anxiety, which is not beneficial for managing binge eating disorder.
B. Plan a menu with the client – Although planning meals can be helpful, remaining with the client after meals is more directly aimed at preventing bingeing behaviors.
C. Remain with the client for 1 hr after meals – Staying with the client after meals helps to monitor for any signs of binge eating behavior and provides support, reducing the likelihood of excessive eating episodes.
D. Offer snacks when the client is hungry – Unstructured snacking can promote impulsive eating and does not assist the client in establishing controlled eating patterns.
Correct Answer is D
Explanation
During the orientation phase, the nurse should introduce herself and the group members, explain the purpose and goals of the group, and create a trusting and respectful atmosphere. Maintaining focus, encouraging problem-solving, and managing conflict are actions that belong to the working phase of group development.
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