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A client at 36 weeks gestation has just delivered a stillborn baby. Which of the following statements should the nurse make?
- A. "I understand your grief. I lost a baby also."
- B. "You may hold your baby as long as you want."
- C. "I have called for the chaplain to come and stay with you."
- D. "This is for the best. Your baby was very ill."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Offering the client the option to hold the stillborn baby allows for the initiation of the grieving process and provides closure. It shows empathy and respect for the client's loss, allowing them to spend time with their baby and say goodbye. This statement acknowledges the client's emotions and offers them control over their grieving process.
Summary of Incorrect Choices:
A: Sharing personal experiences may unintentionally minimize the client's grief and shift the focus away from them.
C: While spiritual support may be beneficial, it may not align with the client's beliefs or preferences.
D: Telling the client that the stillbirth is for the best may come off as insensitive and dismissive of their feelings, causing further distress.
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A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
A nurse in a mental health clinic is attempting to develop a therapeutic relationship with a client. Which of the following actions should the nurse take?
- A. Set limits for the relationship
- B. Promote the use of transference by the client
- C. Instruct the client on how he should behave
- D. Engage in friendly interactions with the client
Correct Answer: A
Rationale: The correct answer is A: Set limits for the relationship. In a therapeutic relationship, setting boundaries and limits is crucial to establish a safe and professional environment. This helps the client understand the expectations and maintain appropriate behavior. By setting limits, the nurse can ensure a therapeutic focus and prevent any potential harm or misunderstandings.
Choice B (Promote the use of transference by the client) is incorrect because encouraging transference can lead to unrealistic expectations and hinder the therapeutic process. Choice C (Instruct the client on how he should behave) is incorrect as it undermines the client's autonomy and may create a power dynamic. Choice D (Engage in friendly interactions with the client) is incorrect as it blurs professional boundaries and may lead to a lack of objectivity.
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
- A. "Perhaps you could call your children to see how they are doing."
- B. "Don't worry. I'll take good care of your parent while you are gone."
- C. "You are feeling drawn in two separate directions."
- D. "There's nothing you can do here. You should go home to your children."
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.
A nurse in a drug and alcohol detoxification center is planning care for a client who has alcohol use disorder. Which of the following interventions should the nurse identify as the priority?
- A. Helping the client identify positive personality traits
- B. Providing for adequate hydration and rest
- C. Confronting the use of denial and other defense mechanisms
- D. Educating the client about the consequences of alcohol misuse
Correct Answer: B
Rationale: The correct answer is B: Providing for adequate hydration and rest. The priority in caring for a client with alcohol use disorder is addressing physical needs like hydration and rest to manage withdrawal symptoms and prevent complications. Hydration helps prevent dehydration and electrolyte imbalances, while rest supports the body's healing process. Choices A, C, and D focus on psychological aspects, which are important but secondary to addressing immediate physical needs. Helping the client identify positive traits can come later in therapy, confronting denial and defense mechanisms can be addressed once the client is stabilized, and educating about consequences is important but not as urgent as ensuring hydration and rest.