Nokea
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
You may also like to solve these questions
A nurse is assessing an outbreak of mumps among school-age children. Using the epidemiological triangle, the nurse should recognize that which of the following is the host?
- A. The vaccine
- B. The virus
- C. The school
- D. The children
Correct Answer: D
Rationale: The correct answer is D: The children. In the epidemiological triangle, the host refers to the organism that harbors the disease. In this case, the school-age children are the host as they are the ones affected by the mumps virus. The virus (option B) is the agent causing the disease, the vaccine (option A) is a preventative measure, and the school (option C) is the environment where transmission may occur but not the host. Therefore, the children (option D) being the individuals who are infected and affected by the mumps outbreak, are correctly identified as the host in this scenario.
A first response team is working at the location of a bombing incident. A nurse triaging a group of clients should give treatment priority to which of the following clients?
- A. A client who has superficial partial-thickness burn injuries over 5% of his body
- B. A client who has a femur fracture with a 2+ pedal pulse
- C. A client who is ambulatory and exhibits manic behavior
- D. A client who has a rigid abdomen with manifestations of shock
Correct Answer: D
Rationale: The correct answer is D: A client who has a rigid abdomen with manifestations of shock. This client should receive treatment priority because a rigid abdomen can indicate internal bleeding or organ damage, which are life-threatening conditions requiring immediate medical attention to prevent further complications. Manifestations of shock, such as hypotension and tachycardia, also indicate a critical condition that needs urgent intervention to stabilize the client's condition and prevent deterioration.
Choice A is incorrect because superficial partial-thickness burn injuries, although painful and requiring treatment, are not immediately life-threatening compared to internal injuries like in choice D. Choice B is incorrect as a femur fracture with a palpable pedal pulse indicates distal circulation is intact, making it a lower priority compared to the critical condition in choice D. Choice C is incorrect as manic behavior, while concerning, does not pose an immediate threat to the client's life compared to the potentially life-threatening conditions in choice D.
A school nurse is planning safety education for a group of adolescents. The nurse should give priority to which of the following topics as the leading cause of death for this age group?
- A. Sports injury prevention
- B. Motor vehicle safety
- C. Substance abuse prevention
- D. Gun safety
Correct Answer: B
Rationale: The correct answer is B: Motor vehicle safety. Adolescents are at a higher risk of motor vehicle accidents, making it the leading cause of death in this age group. This is due to factors like inexperience, risk-taking behaviors, and distractions while driving. Sports injury prevention (A) is important but not the leading cause of death. Substance abuse prevention (C) is significant but not the primary cause of death. Gun safety (D) is also crucial but not as prevalent as motor vehicle accidents.
A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
- A. Have the client's daughter communicate information about the procedure
- B. Arrange for a member of the client's community to interpret the teaching
- C. Identify the client's spoken dialect prior to contacting an interpreter
- D. Use professional terminology when providing education prior to the procedure
Correct Answer: C
Rationale: The correct answer is C: Identify the client's spoken dialect prior to contacting an interpreter. This is the most appropriate action because it ensures effective communication by matching the client with an interpreter who speaks the same dialect. This step shows cultural sensitivity and respects the client's language preference, promoting trust and understanding.
Other choices are incorrect:
A: Having the client's daughter communicate may not guarantee accurate information exchange due to potential language barriers.
B: Arranging for a community member to interpret may not ensure confidentiality or accuracy in communication.
D: Using professional terminology without ensuring understanding may lead to confusion and hinder effective communication.
A community health nurse is providing screening for lipid disorders. Which of the following is the primary goal of this activity?
- A. Early detection of disease
- B. Client enrollment in prevention programs
- C. Promotion of appropriate lifestyle changes
- D. Identification of family history of medical problems
Correct Answer: A
Rationale: The correct answer is A: Early detection of disease. The primary goal of screening for lipid disorders is to identify individuals at risk for developing lipid disorders such as high cholesterol levels. Early detection allows for timely intervention and treatment to prevent complications like heart disease. Choice B is incorrect because enrollment in prevention programs is a secondary outcome of screening, not the primary goal. Choice C is also incorrect as promoting lifestyle changes is a part of the intervention phase, not the primary goal of screening. Choice D is incorrect as identifying family history is important but not the primary goal of screening for lipid disorders.