A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

"You should have asked for help."

"Let's talk about how you were feeling."

"I think you are experiencing guilt."

"Everyone gets discouraged sometimes."

Answer and Explanation

The Correct Answer is B

A.   This response could come across as blaming or judgmental. It implies that the client made a mistake by not seeking help, which can exacerbate feelings of guilt or shame. It does not promote an open dialogue or supportive environment.
B.   This response demonstrates empathy and a willingness to understand the client's emotional state leading up to the suicide attempt. It encourages open communication about the client's feelings and experiences, which is crucial for assessment and intervention planning.
C.   This response suggests that the nurse is making assumptions about the client's emotions without allowing the client to express themselves fully. While guilt may be a common emotion after a suicide attempt, it's important for the nurse to first listen to the client's own description of their feelings.
D.   This response minimizes the seriousness of the client's experience and emotions. It may invalidate the client's feelings of distress or despair that led to the suicide attempt. Such a response does not acknowledge the gravity of the situation or provide the necessary support.

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Correct Answer is D

Explanation

A. Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B. Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C. Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D. Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

A. Lanugo B. Cold extremities C. Hypotension D. Tooth erosion E. Diarrhea

Correct Answer is ["A","B","C","D","E"]

Explanation

A. Lanugo refers to fine, soft hair that can develop on the face, back, and other parts of the body in response to malnutrition and low body fat. It is a compensatory mechanism to help regulate body temperature in individuals with severe weight loss, including those with anorexia nervosa. Therefore, the nurse should expect to find lanugo in a client with anorexia nervosa.
B. Cold extremities are a common finding in individuals with anorexia nervosa due to reduced body fat and poor circulation. The body's natural response to conserve heat is impaired when body fat is extremely low. Therefore, cold extremities are expected in clients with anorexia nervosa.
C. Hypotension, or low blood pressure, can occur in individuals with anorexia nervosa due to dehydration, electrolyte imbalances (such as low potassium levels), and reduced cardiac output. These conditions are often associated with severe malnutrition and can lead to cardiovascular complications. Therefore, hypotension is a potential finding in clients with anorexia nervosa.
D. Tooth erosion can result from frequent vomiting, which is a behavior sometimes seen in individuals with anorexia nervosa, particularly those with purging subtype (anorexia nervosa binge-eating/purging type). Stomach acid from vomiting can damage tooth enamel over time, leading to tooth erosion. Therefore, the nurse should expect to find tooth erosion in clients who engage in purging behaviors.
E. Diarrhea is less commonly associated with anorexia nervosa. Individuals with anorexia nervosa typically have reduced food intake, which can lead to constipation rather than diarrhea. However, in some cases, diarrhea can occur due to malnutrition-related changes in bowel function. It is not a consistent finding but can occasionally be observed.

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A nurse is obtaining a health history from a client who reports a recent suicide attempt. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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