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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. The Michigan Alcohol Screening Test (MAST) is a tool used to screen for alcohol abuse or dependence, but it does not specifically assess withdrawal symptoms.

B. The CAGE questionnaire is used to screen for alcohol abuse, but it does not assess withdrawal symptoms.
C. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA) is a validated tool used to assess the severity of alcohol withdrawal symptoms. It includes various criteria such as agitation, tremor, and hallucinations.
D. The Delirium Rating Scale (DMSE) is used to assess the severity of delirium, which can be caused by various factors including alcohol withdrawal, but it is not specific to alcohol withdrawal.

A. Place metal utensils on the client's meal tray. B. Assign the client to a private room. C. Inspect the client's personal belongings. D. Tuck bedcovers over client's hands and arms.

Correct Answer is C

Explanation

A) Incorrect. Placing metal utensils on the client's meal tray may pose a safety risk, especially considering the recent suicide attempt.

B) Incorrect. Assigning the client to a private room may be beneficial for privacy, but the more immediate concern is ensuring the safety of the client by inspecting personal belongings.

C) Correct. Inspecting the client's personal belongings is crucial to remove any potentially harmful items that the client may use to harm themselves.

D) Incorrect. Tucking bedcovers over the client's hands and arms is not a specific intervention related to the recent suicide attempt.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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