A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Assess for past history of suicide attempts.

Determine whether the client has a specific plan to commit suicide.

Identify coping mechanisms.

Notify all members of the treatment team and place the client on suicide precautions.

Answer and Explanation

The Correct Answer is D

D. Suicide precautions involve implementing safety measures and close monitoring to prevent the client from engaging in self-harm or suicide attempts. This may include continuous observation, removal of

potentially harmful objects or substances from the client's environment, and close supervision by staff members trained in suicide prevention.
A. Assessing for past suicide attempts can provide valuable information about the severity of the client's suicidal ideation, their previous experiences with suicidal behavior, and any patterns or triggers associated with suicidal crises. However, it is not a priority.
B. Assessing for a specific suicide plan allows the treatment team to evaluate the level of risk and urgency of intervention required to keep the client safe. However, with or without a plan, safety should be prioritized.
C. identifying coping mechanisms is important for overall mental health and well-being. However, it is not the priority intervention when a client reports current suicidal ideation.

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Correct Answer is C

Explanation

C. Digoxin toxicity is a serious condition that can occur when there is too much digoxin in the body. It can lead to life-threatening cardiac dysrhythmias. One of the risk factors for digoxin toxicity is low blood levels of potassium, or hypokalemia.
A. Electrolyte imbalances, including hyponatremia (low sodium levels), can contribute to digoxin toxicity. However, a sodium level of 133 mg/dl alone does not directly indicate digoxin toxicity.
B. Blood glucose levels within the normal range (80-120 mg/dl) would not directly indicate digoxin toxicity.
D. Calcium levels within the normal range (8.5-10.5 mg/dl) do not directly indicate digoxin toxicity.

A. is not responding to other clients on the unit. B. angrily argues with another client stating, "God is dead." C. is refusing to take his prescribed mood stabilizer. D. states, "There is no future when you feel so depressed."

Correct Answer is D

Explanation

D. This behavior suggests the possibility of suicidal ideation, which is a medical emergency in mental health care. The nurse should assess the client for suicidal thoughts, intentions, and plans, and provide a safe environment to prevent self-harm. It's crucial to address this as a priority to ensure the safety and well- being of the client.
A. Withdrawing from social interactions can be a symptom of depression. However, it may not always be the highest priority intervention
B. This behavior suggests agitation and potential delusional thinking, which can be indicative of a severe depressive episode or a mixed state in bipolar disorder. This however, does not indicate the need for immediate intervention.
C. Non-adherence to prescribed medication, particularly mood stabilizers, can significantly impact the management of bipolar disorder and increase the risk of mood destabilization. However, addressing adherence is not the priority intervention.

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A client notifies a treatment team member of current suicidal ideation. Which nursing intervention would take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse should monitor the client for signs and symptoms of digoxin toxicity if the laboratory report reflects a serum:

Correct Answer is C

Explanation

A client diagnosed with bipolar disorder is experiencing a severe depressive episode. Which client behavior would alert the nurse to the highest priority intervention? The client:

Correct Answer is D

Explanation

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