A nurse asks a client who is suicidal to make a safety contract, but the client declines.
Which of the following actions should the nurse identify as the priority?.
Assign a staff member to stay with the client at all times.
Lock the doors to the unit and secure windows so they cannot be opened.
Remove any objects from the client's environment that could be used for self-harm.
Provide the client with plastic eating utensils for meals.
The Correct Answer is A
Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Continuing to abstain from alcohol is a positive step towards maintaining mental health, not a sign of suicidal ideation.
Choice B rationale:
Finding therapeutic activities like walking around the hospital grounds is a positive coping mechanism, not a sign of suicidal ideation.
Choice C rationale:
Looking forward to future events like seeing grandchildren is a positive sign and not indicative of suicidal ideation.
Choice D rationale:
Giving away possessions, like a pottery collection, can be a sign of suicidal ideation as it may indicate the client is putting their affairs in order.
Correct Answer is C
Explanation
Choice A rationale:
Flooding therapy is not typically used for somatic symptom disorder.
Choice B rationale:
Telling a client that their pain is not real can invalidate their experience and is not a recommended approach for somatic symptom disorder.
Choice C rationale:
Providing reassurance to the client is a recommended approach when all tests are normal and there are no identified risk factors.
Choice D rationale:
Encouraging the client to request invasive cardiac testing is not typically recommended when all tests are normal and there are no identified risk factors.
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