A client with depression is admitted for voluntary treatment. While in the hospital, the client makes several comments about leaving the facility and kiling themselves with their gun. Which is the most appropriate action by the nurse when the client requests to leave against medical advice?
Call security and ask them to detain the client from leaving.
Contact the client's family to request they convince the client to stay.
Allow the client to leave, with a referral to community resources for follow-up care.
Contact the psychiatrist for initiation of commitment proceedings.
The Correct Answer is D
In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.
Options A, B, and C are not appropriate in this situation:
A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.
B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.
C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
In this situation, the client's safety is of utmost importance. Expressing a desire to leave the facility and harm oneself with a gun raises serious concerns about the client's safety and the risk of harm to themselves. Initiating commitment proceedings, also known as involuntary hospitalization or psychiatric hold, allows the facility to legally detain the client temporarily for their protection and evaluation by mental health professionals. This allows for a thorough assessment of the client's mental health status and the formulation of a comprehensive treatment plan to ensure their safety.
Options A, B, and C are not appropriate in this situation:
A. Calling security to detain the client may escalate the situation and could potentially lead to increased risk of harm.
B. Contacting the client's family may not be enough to ensure the client's safety, and it is essential to involve mental health professionals in evaluating the client's risk.
C. Allowing the client to leave without addressing their expressed suicidal ideation is not safe, as the client may be at high risk for self-harm or suicide. Simply referring them to community resources without further evaluation and intervention is not sufficient to address the immediate safety concern.
Correct Answer is D
Explanation
A-Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data
B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.
C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.
D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs
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