A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Isolate the client from all stressful situations that may precipitate a suicide attempt.

Have a one-to-one sitter for outpatient use.

Identify community resources for the client to use in a crisis.

Educate the family about providing a safe and structured environment for the client.

Assist the client to develop more effective coping mechanisms.

Answer and Explanation

Correct Answer : C,D,E

C. Identifying community resources is essential as it provides the client with accessible support during crises.
D. Educating the family about creating a safe and structured environment is also important because it involves the client's support system in their care, which can help prevent future crises.
E. Assisting the client in developing more effective coping mechanisms is vital for long-term management and recovery, as it empowers the client to handle stressors more healthily.
A. Isolating the client from all stressful situations is not practical or beneficial as it does not teach coping mechanisms or resilience.
B. Having a one-to-one sitter might be necessary in some inpatient settings but is not feasible or indicated for outpatient care.

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Correct Answer is C

Explanation

C. Alcohol withdrawal can lead to dehydration due to symptoms such as vomiting, diarrhea, and increased urination. Replacing fluids is important to prevent dehydration and maintain electrolyte balance.
A. Orienting the individual to reality involves helping them understand their current situation and surroundings. While this is an important aspect of nursing care, it may not be the highest priority during the initial phase of alcohol withdrawal.
B. Social support is vital for individuals undergoing alcohol withdrawal, as it can provide emotional reassurance and assistance during a challenging time. However, during the initial phase of withdrawal, the highest priority is typically addressing immediate physiological needs.
D. Restraints should only be used as a last resort and in situations where there is an imminent risk of harm to the individual or others.

A. discourage the client from discussing feelings of fear and inferiority. B. provide positive reinforcement for acting-out behavior. C. be consistent in staff limit setting. D. ignore, rather than confront, inappropriate behavior.

Correct Answer is C

Explanation

C. This approach involves establishing clear and consistent rules and boundaries, which are crucial for managing antisocial behaviors. It helps to create a structured environment where the consequences of actions are predictable and reinforces the understanding of acceptable behaviors.
A. Encouraging the client to explore and address underlying emotions, including feelings of fear and inferiority, can be an important aspect of therapy and may help mitigate manipulative behaviors over time.
B. Antisocial personality disorder is associated with behaviors that violate social norms and the rights of others. Positive reinforcement for these behaviors would not address the underlying issues and may inadvertently reinforce harmful patterns of behavior.
D. Ignoring inappropriate behavior may reinforce the notion that manipulation is an effective means of achieving desired outcomes and may lead to further boundary violations.

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A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The highest priority nursing action relative to the initial phase of alcohol withdrawal would be to:

Correct Answer is C

Explanation

The intervention appropriate for a client who has been manipulating others and has a diagnosis of antisocial personality disorder is to:

Correct Answer is C

Explanation

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