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A client who has major depressive disorder states to the nurse that he and his family would be better off if he were gone. Which of the following is the nurse’s priority response?
- A. "Do you really think your family would be better off without you?"
- B. "Tell me what is happening right now."
- C. "Have you thought of harming yourself?"
- D. "When did you first start feeling this way?"
Correct Answer: C
Rationale: The correct answer is C: "Have you thought of harming yourself?" because it addresses the immediate safety concern of suicidal ideation. It is crucial to assess the client's risk of self-harm or suicide first. Choice A is not a direct inquiry about self-harm. Choice B focuses on the current situation but does not address the suicidal statement. Choice D is more about exploring the history of depressive symptoms rather than assessing immediate risk.
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A nurse is assessing a client experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Increased energy
- C. Increased cognitive awareness
- D. Hyperglycemia
Correct Answer: D
Rationale: The correct answer is D: Hyperglycemia. Chronic stress can lead to the release of stress hormones like cortisol and adrenaline, which can increase blood sugar levels. This occurs due to the body's fight-or-flight response to stress. Hypotension (A) is unlikely as stress typically leads to increased blood pressure. Increased energy (B) is less likely as chronic stress can lead to fatigue and exhaustion. Increased cognitive awareness (C) is not a common finding in chronic stress, as it can impair cognitive function. Hyperglycemia (D) is the most likely finding due to the physiological response to stress.
A nurse is making a home visit to a client who has Alzheimer's disease and the client's partner. Which of the following observations indicates to the nurse that the partner is experiencing caregiver role strain?
- A. The partner has placed locks at the top of the doors leading to the outside.
- B. The partner has hired a house cleaner.
- C. The partner has lost 20 lb in the past 2 months.
- D. The partner redirects the client when the client is frustrated.
Correct Answer: C
Rationale: The correct answer is C because the partner losing 20 lb in the past 2 months indicates caregiver role strain. Significant weight loss can be a sign of stress, neglecting self-care, and being overwhelmed by caregiving responsibilities. This observation suggests that the partner may not be prioritizing their own well-being while caring for the client with Alzheimer's disease.
Choice A is incorrect because placing locks at the top of doors is a safety measure commonly taken to prevent the client with Alzheimer's disease from wandering outside unsupervised. Choice B is incorrect as hiring a house cleaner can be a practical solution to manage household tasks and does not necessarily indicate caregiver role strain. Choice D is incorrect because redirecting the client when frustrated is a positive caregiving technique to manage challenging behaviors.
A nurse is caring for a client who has schizophrenia and tells the nurse, "They lie about me all the time, and they are trying to poison my food." Which of the following statements should the nurse make?
- A. "You are mistaken. Nobody is lying about you or trying to poison you."
- B. "You seem to be having very frightening thoughts."
- C. "Why do you think you are being lied about and poisoned?"
- D. "Who is lying about you and trying to poison you?"
Correct Answer: B
Rationale: The correct answer is B: "You seem to be having very frightening thoughts." This response acknowledges the client's feelings without denying or confirming the delusions. It shows empathy and validates the client's experience without reinforcing the delusions. Option A is incorrect as it denies the client's beliefs, which can lead to distrust. Option C may encourage the client to provide more details about the delusions. Option D may inadvertently validate the delusions by asking for specific details.
A nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?
- A. "Using nontraditional treatments is not a good idea. I'd rather you avoid that route."
- B. "Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you."
- C. "A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice."
- D. "Tell me more about your concerns about taking chemotherapy."
Correct Answer: D
Rationale: Exploring the client’s concerns helps build trust and encourages shared decision-making.
A nurse observes that a client who has depression is sitting alone in the room crying. As the nurse approaches, the client states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses should the nurse make?
- A. "It might help you feel better if you talk about it."
- B. "I'll just sit here with you for a few minutes then."
- C. "I understand. I've felt like that before, too."
- D. "Why are you feeling so down?"
Correct Answer: B
Rationale: The correct answer is B: "I'll just sit here with you for a few minutes then." This response demonstrates empathy and support without imposing solutions or pressuring the client to talk. It acknowledges the client's feelings and offers companionship, which can provide comfort and reassurance. Choice A may pressure the client to talk, which may not be what the client needs at the moment. Choice C shifts the focus to the nurse's own experiences, which may not be helpful for the client. Choice D may come across as confrontational or dismissive of the client's emotions. Therefore, choice B is the most appropriate response in this situation.