A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Reassure the client that everything is going to work out.

Ask the client about the lethality of their plan.

Allow the client time alone to self-reflect

Encourage the client to focus on the positive aspects of life.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.

B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.

C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.

D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.

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Correct Answer is D

Explanation

Rationale:

A. A blood pressure of 102/66 mm Hg is within normal limits for a postoperative client.

B. Straw-colored urine is a normal finding for a postoperative client.

C. A respiratory rate of 18/min is within normal limits.

D. Yellow-green drainage from the surgical incision can indicate infection or other complications and should be reported to the provider for further evaluation.

A. Report the incident to the other RNS on the shift. B. Agree to not report the incident if the coworker seeks treatment. C. Report the incident to the appropriate person in the chain of communication D. Agree to not report the incident if the coworker promises to report

Correct Answer is C

Explanation

Rationale:

A. Reporting the incident to other RNs on the shift does not ensure that the appropriate actions will be taken to address the issue.

B. Agreeing not to report the incident in exchange for the coworker seeking treatment is unethical and does not follow the correct reporting protocol.

C. Reporting the incident to the appropriate person in the chain of communication, such as a supervisor or nurse manager, is the correct course of action. This ensures that the situation is handled according to hospital policy and legal requirements, protecting patient safety and addressing the coworker's substance use disorder.

D. Agreeing not to report the incident if the coworker promises to report themselves is also unethical and fails to meet professional responsibilities.

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A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 48 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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