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 B

Explanation

A. It is not effective to repeatedly ask orientation questions to a client with dementia. Dementia causes progressive memory loss and cognitive decline, and the client may not be able to provide the correct response even with repeated questioning. This approach can lead to frustration and agitation for the client.
B. Introducing oneself at each interaction is a good practice because individuals with dementia may have difficulty remembering people or recognizing familiar faces. It helps establish rapport and reduces confusion or anxiety that may arise from not recognizing caregivers or staff.
C. Providing choices can help empower the client and maintain some level of independence in decision- making. However, it's important to keep the choices limited and clear, as too many options can overwhelm and confuse a person with dementia. Additionally, offering familiar and preferred foods can enhance the client's comfort and enjoyment of meals.
D. Providing a dark environment for sleeping may not be appropriate for all clients with dementia. Some individuals may become disoriented or agitated in complete darkness. It's generally recommended to provide a quiet and calm environment with subdued lighting during nighttime hours to support restful sleep.

A. Administer an antianxiety medication. B. Calculate the client's score on the Hamilton Rating Scale for Anxiety. C. Discuss the benefits of relaxation exercises with the client. D. Explain the use of response prevention to the client.

Correct Answer is D

Explanation

A. While medications like SSRIs (Selective Serotonin Reuptake Inhibitors) or benzodiazepines may eventually be part of the treatment plan for OCD, administering medication should not be the first action unless the client is in acute distress or experiencing severe anxiety symptoms that require immediate pharmacological intervention.
B. This option involves assessing the severity of anxiety symptoms, which is important for understanding the client's baseline anxiety level. However, calculating this score is not the first action. It can be done later as part of the comprehensive assessment to guide ongoing treatment planning.
C. Relaxation exercises, such as deep breathing or progressive muscle relaxation, can help manage anxiety symptoms in clients with OCD. However, before initiating specific interventions like relaxation exercises, the nurse should first establish rapport, assess the client's current level of distress, and gather information about the client's symptoms and coping mechanisms.
D. Response prevention is a cognitive-behavioral therapy technique used in the treatment of OCD, where clients are prevented from engaging in compulsive behaviors. This should follow after thorough assessment of the actual psychological state of the client.

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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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Explanation

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Correct Answer is D

Explanation

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