A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

Reviewing the client's toxicology laboratory report.

Initiating suicide precautions.

Making a contract with the client for eating behavior.

Administering the Hamilton Depression Scale.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.

Choice B rationale:

Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.

Choice C rationale:

Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.

Choice D rationale:

Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.

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Correct Answer is C

Explanation

The correct answer is choice C.

Choice A rationale:

Planning a therapeutic diet is important for overall client care, but it might not be the first priority. The client's significant weight loss and distorted body image require more immediate attention to address potential underlying mental health concerns..

Choice B rationale:

Providing a structured environment is beneficial, but it might not be the first priority in this situation. The client's distorted perception of weight and significant weight loss necessitate more immediate assessment and intervention.

Choice C rationale:

Assessing the client's nutritional status is the first priority in this scenario. The client's weight loss of 11 kg (25 lb) over 3 months and belief that she is fat are indicators of a possible eating disorder. Nutritional assessment helps determine the severity of the issue and guides appropriate interventions.

Choice D rationale:

While requesting a mental health consult is important, it is not the first priority. Addressing the client's immediate physical health, which includes assessing her nutritional status and potential risk for complications related to her distorted body image, takes precedence.

A. "You are feeling very depressed. I felt the same way when I decided to leave my husband.” B. "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.” C. "You seem depressed. It was a difficult decision to make. Would you like to talk about it?” D. "I know this is a difficult time for you. Would you like medication for anxiety?”

Correct Answer is A

Explanation

Choice A rationale:

The statement "You are feeling very depressed. I felt the same way when I decided to leave my husband." is a non-therapeutic statement that demonstrates sympathy. The nurse is sharing personal experiences, which can shift the focus from the client's feelings to the nurse's own experiences.

Choice B rationale:

The statement "I can understand you are feeling depressed. It was a difficult decision. I'll sit with you." is a therapeutic response that offers support and empathy without diverting the focus to the nurse's experiences. The nurse's willingness to sit with the client is a positive aspect of this response.

Choice C rationale:

The statement "You seem depressed. It was a difficult decision to make. Would you like to talk about it?" is a therapeutic response that acknowledges the client's feelings, offers support, and invites further conversation. This response encourages the client to express themselves.

Choice D rationale:

The statement "I know this is a difficult time for you. Would you like medication for anxiety?" acknowledges the client's difficulties but immediately offers medication as a solution. While medication can be a valid option, it's important to prioritize open communication and emotional support before suggesting medication.

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A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the ER is admitting a client who has experienced a weight loss of 11 kg (25 lb) in the past 3 months. The client weighs 40 kg (88 lb) and believes she is fat. Which of the following aspects of care should the nurse consider the first priority for this client?

Correct Answer is C

Explanation

A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?

Correct Answer is A

Explanation

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