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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Semaglutide is a medication used for diabetes management and weight loss, not for PTSD.
B. Paroxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed for PTSD to help manage symptoms of depression and anxiety.
C. Tramadol is a pain medication and is not used for managing PTSD symptoms.
D. Zalepion is a sleep aid, and while sleep disturbances are common in PTSD, it is not a first-line treatment for the disorder itself.
Correct Answer is D
Explanation
Rationale:
A. The medication administration record is important for verifying the order but should be used in conjunction with the patient’s identification.
B. The order sheet provides the details of the blood product to be administered but is not the primary source for verifying patient identity.
C. The chart includes medical history and orders but does not provide direct patient identification for blood administration.
D. The identification wristband is the primary and most direct method for verifying the patient’s identity to ensure that the correct blood product is administered to the correct patient.
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