A client has been diagnosed with depression and has a history of suicide attempts. What intervention is essential for the nurse to implement?
Leaving the client alone to give them space.
Removing any potential means of self-harm from the client's environment.
Encouraging the client to confront their feelings of hopelessness.
Telling the client that they should be grateful for what they have.
The Correct Answer is B
Choice A rationale:
Leaving the client alone to give them space is not a suitable intervention for someone with a history of suicide attempts and depression. Isolation can increase the risk of acting on suicidal thoughts, and the client needs close monitoring and support during this vulnerable time.
Choice B rationale:
Removing any potential means of self-harm from the client's environment is essential. This intervention helps reduce the immediate risk by limiting access to harmful items. It's a crucial step in creating a safer environment for the client and preventing impulsive acts of self-harm.
Choice C rationale:
Encouraging the client to confront their feelings of hopelessness is important, but it should be done in a supportive and therapeutic manner. Simply telling someone to confront their feelings without appropriate guidance can be overwhelming and unproductive.
Choice D rationale:
Telling the client that they should be grateful for what they have minimizes their emotional experience and does not address the complexity of depression and suicidal ideation. This statement lacks empathy and understanding of the client's struggles.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Modifying the plan of care based on the patient's current status is a fundamental aspect of the evaluation phase. Patients' conditions can change, and the plan of care should be flexible enough to adapt to their evolving needs. By making necessary adjustments, the nurse ensures that the patient continues to receive appropriate and effective care.
Choice B rationale:
Comparing the patient's current status with baseline data only is insufficient for a comprehensive evaluation. Baseline data is useful for establishing a starting point, but it doesn't account for changes that may have occurred since then. Effective evaluation involves considering both baseline data and the patient's current condition.
Choice C rationale:
Disregarding the patient's feedback about their care is not appropriate during the evaluation phase. Patient feedback provides valuable insights into their experience, concerns, and whether the current plan of care is meeting their needs. Ignoring their feedback can lead to unaddressed issues and a lack of patient-centered care.
Choice D rationale:
Documenting outcomes without assessing the patient's response undermines the purpose of the evaluation phase. Evaluation involves not only documenting outcomes but also assessing how the patient has responded to interventions. This assessment informs whether the outcomes are positive, need adjustment, or require a different approach.
Correct Answer is C
Explanation
Choice A rationale:
Advising the client to keep their feelings to themselves is not an appropriate intervention in this situation. Suicidal ideation is a serious concern, and keeping feelings hidden could potentially lead to the client not receiving the necessary support and intervention they need to stay safe.
Choice B rationale:
Encouraging the client to isolate themselves until they feel better is not an appropriate intervention either. Isolation can exacerbate feelings of hopelessness and increase the risk of acting on suicidal thoughts. Connecting with the client and providing a supportive environment is crucial.
Choice C rationale:
Asking the client directly if they are thinking about harming themselves is the most appropriate intervention. This approach helps the nurse assess the severity of the situation, open a dialogue about the client's feelings, and determine the level of risk. Direct communication allows for a better understanding of the client's mental state and the need for further intervention.
Choice D rationale:
Providing the client with alcohol or drugs to help them cope is a dangerous and inappropriate intervention. Substance use can further impair judgment and increase the risk of acting on suicidal thoughts. This action also fails to address the underlying issues contributing to the client's distress.
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