Nokea
A client who is experiencing suicidal thoughts shares with the nurse that, 'I was awake most of the night. It just doesn't seem worth it anymore. Why not just end it all?' Which response should the nurse make to best further assess the client?
- A. Did you sleep at all last night?
- B. Tell me what you mean by that.
- C. I know you have had a stressful night.
- D. I'm sure that your family is worried about you.
Correct Answer: B
Rationale: Option 2 allows the client the opportunity to tell the nurse more about what his or her current thoughts are. Option 1 changes the subject and may block communication. Although option 3 offers empathy to the client, it does not further assess the client. Option 4 is false reassurance and may block communication.
You may also like to solve these questions
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
Which statement made by a client who has experienced a spinal cord injury resulting in chronic immobility issues warrants immediate follow-up by the nurse to assure client safety?
- A. I'm so angry that this happened to me.
- B. I really don't want to live my life like this.
- C. I'm definitely not looking forward to going home.
- D. I don't know if I can make all these major adjustments to my life.
Correct Answer: B
Rationale: It is important to allow the client with a spinal cord injury to verbalize her or his feelings. If the client indicates a desire to discuss her or his feelings, the nurse should respond therapeutically. Expressions of hopelessness or despair require immediate attention because they can indicate that the client is harboring suicidal ideations. Although the remaining statements require follow-up, they lack that serious component of despair and/or hopelessness.
A male client is admitted to the hospital diagnosed with diabetic ketoacidosis (DKA). The client's daughter says to the nurse, 'My mother died last month, and now this. I've been trying to follow all of the instructions the doctor gave my dad, but what have I done wrong?' Which therapeutic response should the nurse make to the client's daughter?
- A. Tell me what you think you did wrong.'
- B. Maybe we can keep your father in the hospital for a while longer to give you a rest.'
- C. You should talk to the social worker about getting you someone at home who has more experience managing a diabetic's care.'
- D. An emotional stress such as your mother's death can trigger DKA in a diabetic client, even though the prescribed regimen is being followed.'
Correct Answer: D
Rationale: Environment, infection, or an emotional stressor can initiate the physiological mechanism of DKA. Options 1 and 3 substantiate the daughter's feelings of guilt and incompetence. Option 2 is not a cost-effective intervention.
The nurse conducts a grief support group at the community mental health center. Which client will the nurse identify as needing additional assistance before participating in this group?
- A. Older adult male whose estranged spouse, living in another state, died from heart disease 3 months ago.
- B. Older adult female whose spouse died 3 years ago in a car accident.
- C. Middle-aged female who started drinking after the sudden death of the spouse 6 months ago.
- D. Young male with two children whose spouse died 1 year ago due to breast cancer.
Correct Answer: C
Rationale: The middle-aged female who began drinking after her spouse’s death indicates unhealthy coping and potential substance abuse, requiring individual intervention before group participation. Other clients show grief but no immediate maladaptive behaviors.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for altered sensory perception, especially during stressful events like surgery. Other clients (A, C, D) have no specific sensory risks indicated.