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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Walk with the client at a gradually slower pace.
Choice A rationale:
Instructing the client to sit down and stop pacing (Choice A) might come across as authoritarian and dismissive of the client's anxiety. It's important to provide a more supportive and empathetic approach.
Choice B rationale:
Having a staff member escort the client to her room (Choice B) might further escalate the client's anxiety. The client may interpret this action as a form of containment or punishment.
Choice C rationale:
Walk with the client at a gradually slower pace (Choice C) is the most appropriate action. This approach acknowledges the client's anxiety and provides a calming presence. Gradually slowing down can help the client naturally transition from pacing to a calmer state.
Choice D rationale:
Allowing the client to pace alone until physically tired (Choice D) might prolong the episode of anxiety. Providing support and engagement is essential in managing the client's distress effectively.
Correct Answer is A
Explanation
Choice A rationale:
In a democratic leadership style, the leader involves the group in decision-making and encourages open discussion. By asking the group for their input on resolving the bathroom issue, the nurse is demonstrating democratic leadership.
Choice B rationale:
A surrogate leadership style involves a designated individual acting as a substitute for the leader. It's not applicable in this scenario where the nurse is involving the group in decision-making.
Choice C rationale:
Laissez-faire leadership involves minimal interference and decision-making by the leader. In this scenario, the nurse is actively seeking group input, which contradicts the laissez-faire approach.
Choice D rationale:
An autocratic leadership style involves the leader making decisions without group input. Since the nurse is soliciting ideas from the group, this style doesn't apply here.
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