The home health aide reports to the practical nurse that the client has been trying to give away possessions.
When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?
“Tell me more about how you’re feeling.”.
“You’re not thinking of killing yourself, are you?”
“Have you thought of therapy?”
“Let’s discuss some coping strategies.”.
The Correct Answer is A
Choice A rationale
When a client expresses feelings of hopelessness and exhibits behaviors such as giving away possessions, it is crucial for the nurse to further explore these feelings. Asking the client to elaborate on their feelings allows the nurse to gather more information and assess the severity of the client’s emotional state. It also communicates to the client that the nurse is there to listen and provide support.
Choice B rationale
While it is important to assess for suicidal ideation in clients expressing hopelessness, asking directly, “You’re not thinking of killing yourself, are you?” can come across as confrontational and may cause the client to become defensive or close off.
Choice C rationale
Suggesting therapy is a potential intervention, but it is not the best initial response. The immediate priority is to assess the client’s emotional state and risk for self-harm.
Choice D rationale
Discussing coping strategies may be beneficial once the client’s immediate emotional state and safety have been addressed. However, it is not the best initial response when a client is expressing intense feelings of hopelessness.
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Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
Choice A rationale
While making a verbal contract not to harm oneself can be a part of suicide prevention strategies, it is not the immediate responsibility in this scenario. The client’s erratic behavior and expressions of despair indicate a high level of distress and potential risk for self-harm.
Choice B rationale
Returning the client to the waiting room with the spouse does not ensure the client’s safety. The spouse may not be equipped to manage the client’s current emotional state, and the busy environment of the waiting room may exacerbate the client’s distress.
Choice C rationale
Documenting that the client is not currently suicidal is not appropriate in this situation. The client’s non-verbal cues (shrugging their shoulders when asked about suicidal thoughts) may indicate ambivalence or uncertainty about their intent to harm themselves.
Choice D rationale
Placing the client in an inside hallway with one-on-one observation is the most appropriate action. This ensures the client’s safety, allows for continuous monitoring of the client’s condition, and provides an opportunity for further assessment and intervention.
Correct Answer is A
Explanation
Impaired self-care is a common symptom of depression. Individuals with depression may struggle with daily tasks such as bathing, dressing, and eating. This can be due to a lack of energy, decreased motivation, or feelings of worthlessness.
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