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 D
Explanation
The correct answer is choiced. "So, it seems that you feel responsible for what happened to your mother.”
Choice A rationale:This response attempts to reassure the son but may come off as dismissive of his feelings. It does not encourage further discussion or exploration of his emotions.
Choice B rationale:This response is overly reassuring and dismisses the son’s feelings of guilt. It does not address his emotional state or encourage him to express his concerns.
Choice C rationale:This response questions the son’s feelings directly, which might make him defensive. It does not validate his emotions or encourage him to talk more about his feelings.
Choice D rationale:This response acknowledges the son’s feelings and encourages him to express his emotions. It is a therapeutic communication technique that helps the son feel heard and understood, which is crucial in providing emotional support.
Correct Answer is A
Explanation
Choice A rationale:
"His cousin committed suicide a few weeks ago." This statement is a significant red flag indicating a higher risk of suicide. When an adolescent is exposed to suicide, especially within their family or close social circle, they become more vulnerable due to the potential for social contagion. This scenario increases the urgency for intervention and support to prevent a similar outcome.
Choice B rationale:
"He spends much of his time with his two school friends." While changes in social behavior might raise concerns, this statement alone does not directly indicate a risk of suicide. Adolescents can experience shifts in their social preferences for various reasons, and it's not a definitive sign of suicidal ideation or intent.
Choice C rationale:
"He has slept 9 hours each night for the past 2 years." Sleeping patterns alone do not strongly correlate with suicide risk. However, drastic changes in sleep patterns, such as insomnia or hypersomnia, might be indicative of underlying mental health issues. In this case, the consistent sleep pattern mentioned does not directly signal a risk of suicide.
Choice D rationale:
"He is very religious and attends services twice a week." Religious involvement can have protective effects on mental health, and attending religious services can provide a support network. While religion might offer some resilience against suicide, it is not a definitive indicator. Other factors need to be considered in conjunction with religious activities. For , the statement indicating an adolescent's higher risk of suicide is "His cousin committed suicide a few weeks ago" (Choice A). This experience increases the risk due to the potential for social contagion. The other options, including spending time with school friends, sleep patterns, and religious involvement, do not directly suggest an imminent risk of suicide.
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