A client is brought to a busy emergency department by their spouse due to erratic behavior and expressions of despair.

If the client shrugs their shoulders when asked by the triage registered nurse if they feel suicidal now, what nursing responsibility is the practical nurse expected to be assigned?

Ask the client to make a verbal contract to not harm self.

Return the client to the waiting room with the spouse.

Document that the client is not currently suicidal.

Place the client in an ideal situation with one-on-one observation.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.

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Correct Answer is C

Explanation

Choice C rationale
Assisting the patient in identifying a thought that triggers anger, evaluating the validity of the belief, and replacing it with reality-based thinking is an effective nursing intervention to help an angry patient manage their anger without resorting to violence. This approach is based on cognitive behavioral therapy (CBT), a type of psychotherapy that can help people learn to identify and change destructive thought patterns that have a negative influence on behavior and emotions.
Choice A rationale
While medication can be part of a comprehensive treatment plan for individuals struggling with anger management, it is not the first-line intervention. Medication should be considered if the anger is part of a larger mental health disorder, such as bipolar disorder or intermittent explosive disorder, and should be administered under the guidance of a healthcare provider.
Choice B rationale
Negative reinforcement such as restraint or seclusion can escalate the situation and is not considered a best practice for managing anger. It should only be used as a last resort when the patient poses a risk to themselves or others.
Choice D rationale
Aversive conditioning, such as snapping a rubber band on the wrist, is a type of behavioral therapy that can be used to help a person reduce or eliminate unwanted behaviors. However, it is not the most effective strategy for managing anger and can potentially lead to self-harm.

A. Tell me more about what you are feeling. B. It must be difficult for you to feel that way. C. You should talk to your husband and not keep things inside. D. Everything will turn out fine.

Correct Answer is ["C","D"]

Explanation

Choice A rationale
This response encourages the patient to express their feelings and promotes open communication. It is a therapeutic communication technique.
Choice B rationale
This response shows empathy and validates the patient’s feelings. It is a therapeutic communication technique.
Choice C rationale
This response could obstruct effective communication as it tells the patient what they should do. It does not encourage the patient to express their feelings or promote open communication.
Choice D rationale
This response could obstruct effective communication as it offers false reassurance. It does not acknowledge the patient’s feelings or concerns.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is an effective nursing intervention to help an angry patient manage their anger without resorting to violence?

Correct Answer is C

Explanation

In communicating with the psychiatric patient, which nurse responses could obstruct effective communication with a client? (Select all that apply)

Correct Answer is ["C","D"]

Explanation

Feelings of worthlessness, guilt, and despair are expressed in a female client’s every thought, movement, and activity. Her physical health has declined and she is often unable to eat. What is the client experiencing?

In a psychiatric unit, how are bright colors in the client’s environment often perceived?

The home health aide reports to the practical nurse that the client has been trying to give away possessions. When the nurse asks the client about this behavior, the client says, “With my spouse dead, there’s no reason for me to go on.”. What is the best priority response by the nurse?

True or False: A person with severe depression may sleep excessively.

A patient with a history of suicidal ideation is under observation. When is the patient at the highest risk for self-harm?

A client who recently went through an upsetting divorce is threatening to commit suicide with a handgun. The client is voluntarily admitted to the psychiatric unit. Which of the following nursing diagnoses has the highest priority?