A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
"Who do you talk to when you feel overwhelmed?"
"Are you thinking about harming yourself?"
"Can we talk about how your partner's death has affected you?"
"What do you usually do to calm your thoughts?"
The Correct Answer is B
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.
Choice B rationale:
This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.
Choice C rationale:
This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.
Choice D rationale:
A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.
Correct Answer is C
Explanation
Choice A rationale:
Placing the client on a low-protein diet is not appropriate based solely on the provided information.
Choice B rationale:
Restricting dietary sodium might be considered for specific conditions but is not directly related to the client's confusion.
Choice C rationale:
A high magnesium level can contribute to confusion in older adults. Requesting a reduction in the magnesium hydroxide dosage can help address this issue.
Choice D rationale:
Discontinuing diphenhydramine might be considered if it is contributing to the client's confusion, but there is no specific information provided to support this action.
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