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 D
Explanation
The correct answer is: D. The client has several siblings.
Choice A reason:
The client being the oldest of their siblings is not directly linked to the development of conduct disorder. Conduct disorder is more influenced by factors such as family conflict, inconsistent discipline, and parental issues rather than birth order.
Choice B reason:
The client's father living in the client's home does not inherently contribute to conduct disorder. The presence of a father figure can be a stabilizing factor unless there are issues such as abuse, neglect, or inconsistent parenting.
Choice C reason:
The client's mother having asthma is unrelated to the development of conduct disorder. Conduct disorder is typically associated with psychological, social, and familial factors rather than the physical health conditions of parents.
Choice D reason:
The client having several siblings can contribute to conduct disorder due to potential for increased familial conflict and competition for parental attention. Larger family sizes can sometimes lead to less individual attention and more sibling rivalry, which can exacerbate behavioral issues.
Correct Answer is D
Explanation
The client's guardian is the legal representative who can provide informed consent for the client who is incompetent. The nurse should ensure that the guardian understands the risks, benefits, and alternatives of the proposed treatment or procedure.
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