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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While fostering a social relationship can be a part of therapeutic communication, it is not the primary goal. The main focus is on the client’s needs and concerns.
Choice B rationale
Focusing on the attitude of the client is not the primary goal of therapeutic communication. The main goal is to understand the client’s experiences and feelings.
Choice C rationale
The primary goals of therapeutic communication are to focus on the client and to build a rapport. This involves understanding the client’s needs, concerns, and emotions effectively.
Choice D rationale
Focusing on the staff member and building rapport is not the primary goal of therapeutic communication. The main focus should be on the client.
Correct Answer is D
Explanation
Choice D rationale
Delirium is a sudden onset of confusion that can be caused by a variety of factors, including withdrawal from certain medications like lorazepam. Symptoms can include disorientation, difficulty focusing, short-term memory loss, and increased lethargy.
Choice A rationale
Psychosis is a severe mental disorder characterized by a disconnection from reality. It often involves hallucinations or delusions, which are not mentioned in the scenario.
Choice B rationale
Dementia is a chronic or persistent disorder of the mental processes caused by brain disease or injury. It is marked by memory disorders, personality changes, and impaired reasoning. It typically does not have a sudden onset.
Choice C rationale
Amnesia is a condition in which one’s memory is lost or disturbed. It can be caused by brain injury or severe emotional trauma. The scenario does not provide information suggesting the patient has experienced a loss of memory.
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