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A nurse is caring for a client who is dying. The client says, "My mother died in the hospital, but I did not get there before she died." Which of the following statements should the nurse make?
- A. "We will call your family in time for them to get here."
- B. "I wonder if you are fearful of dying alone."
- C. "I will make sure a staff member is in your room at all times."
- D. "I will tell your family of your concern so that they can be here."
Correct Answer: B
Rationale: The correct answer is B: "I wonder if you are fearful of dying alone." This response shows empathy and addresses the client's emotional needs. It acknowledges the client's fear and opens up a conversation about their concerns. It allows the client to express their feelings and provides an opportunity for therapeutic communication.
Choice A is incorrect because it only focuses on calling the family and does not address the client's emotional state. Choice C is incorrect as it only ensures physical presence but does not address the client's emotional needs. Choice D is incorrect as it shifts the responsibility to the family without acknowledging the client's feelings.
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A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?
- A. Call for assistance to place the client in restraints.
- B. Escort the client to an unlocked seclusion room.
- C. Offer the client a PRN antianxiety medication.
- D. Speak to the client calmly, giving simple directions.
Correct Answer: D
Rationale: The correct answer is D: Speak to the client calmly, giving simple directions. This is the first action the nurse should take because it focuses on de-escalating the situation and ensuring the safety of the client and others. By speaking calmly and giving simple directions, the nurse can help the client regain control and potentially prevent further escalation. Calling for assistance to place the client in restraints (A) should only be used as a last resort for safety reasons. Escorting the client to an unlocked seclusion room (B) may escalate the situation further. Offering a PRN antianxiety medication (C) should only be considered after assessing the client and obtaining an order from a healthcare provider.
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- A. Substance use disorder
- B. Age greater than 45 years old
- C. Female gender
- D. Currently married
- E. Schizophrenia
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. Substance use disorder is a known risk factor for suicide as it can lead to increased impulsivity and impaired decision-making. Age greater than 45 years old is a risk factor due to factors such as isolation, health issues, and life changes. Schizophrenia is associated with a higher risk of suicide due to the symptoms of the disorder and the impact on one's mental well-being. Choices C and D are incorrect as being female or currently married are not universal risk factors for suicide. The absence of choices F and G also indicates that they are not relevant risk factors for suicide.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A client who is about to undergo abdominal surgery states that he is very anxious about the operation. Which of the following responses should the nurse make?
- A. Ask him to describe what he is feeling.
- B. Give the client some reading material as a distraction.
- C. Suggest that he take a walk around the unit.
- D. Refer him to the pastoral care team.
Correct Answer: A
Rationale: The correct response is A: Ask him to describe what he is feeling. This option encourages the client to express his emotions, which can help alleviate anxiety by providing an outlet for his concerns. By actively listening and acknowledging his feelings, the nurse can establish trust and rapport, leading to better emotional support. Choice B may provide a temporary distraction but does not address the underlying anxiety. Choice C may be physically beneficial but does not address the client's emotional state. Choice D may be helpful for spiritual support but does not directly address the client's anxiety.