A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?
Placing the client on one-on-one observation while monitoring for suicidal ideations
Conducting 15minute checks to ensure safety
Encouraging the client to verbalize feelings related to suicide
Completing a room search to ensure there are no harmful objects available to the client.
The Correct Answer is A
A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This
intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.
B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.
C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.
D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) Incorrect. While the client's sleep disturbance and lack of selfcare may contribute to
ineffective health maintenance, the more immediate concern is addressing the risk of imbalanced nutrition.
B) Incorrect. While clients in a manic state may exhibit hyperactivity and impulsivity, there is no indication in the scenario that the client poses an immediate risk for other-directed violence.
C) Correct. The client's reported lack of sleep and refusal to eat for an extended period raises concerns about nutritional deficits and dehydration. This is the most immediate and pressing issue to address.
D) Incorrect. While the client's manic state may increase the risk of impulsive behavior, there is no specific indication in the scenario that the client is at immediate risk for suicide.
Correct Answer is ["A","D","F"]
Explanation
A) Correct. Given the nature of the accident, there is a high risk for traumatic brain injury. This should be a priority for screening and assessment.
B) Incorrect. While chronic pain may be a concern, it is not directly related to the recent accident and is not a priority for screening at this time.
C) Incorrect. Sexual dysfunction is not directly related to the recent accident and is not a priority for screening at this time.
D) Correct. The client's request for early discharge and the recent traumatic event raise concerns about potential depression. Screening for depression is important.
E) Incorrect. Effective coping strategies are important, but they are not a priority for screening in this scenario.
F) Correct. Given the recent accident and the client's expressed desire for early discharge, there may be an increased risk for suicide. This should be a priority for screening and assessment.
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