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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Correct. Confusion is a common side effect following ECT. It is usually temporary and gradually resolves.
B) Incorrect. Long-term memory impairment is a potential side effect of ECT, but it is not immediate and is more of a concern with repeated sessions.
C) Incorrect. Feeling full of energy would not be an expected immediate side effect of ECT.
D) Incorrect. Numbness and tingling in the extremities are not typically associated with ECT.
Correct Answer is C
Explanation
A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.
B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.
C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.
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