A nurse is assisting with planning of care for a client following a suicide attempt. Which of the following interventions is an appropriate suicide precaution?
Inspect the client's personal belongings.
Assign the client to a private room.
Tuck bedcovers over client's hands and arms.
Remove utensils from the client's meal trays.
The Correct Answer is A
A. Inspect the client's personal belongings. Inspecting the client's personal belongings helps to ensure that the client does not have access to items that could be used for self-harm, such as sharp objects or medications.
B. Assign the client to a private room. Assigning a client who has attempted suicide to a private room can increase isolation and the risk of self-harm, as they are not easily observed.
C. Tuck bedcovers over client's hands and arms. This intervention is not effective and could potentially restrict the client's movement, increasing feelings of distress.
D. Remove utensils from the client's meal trays. Removing utensils, especially sharp ones, from meal trays helps to prevent the client from using them to harm themselves.
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Correct Answer is D
Explanation
A. Take a time-out: A time-out is generally used for de-escalating situations in less severe cases and may not be effective if the client is already physically aggressive and a risk to staff.
B. Administer oral medication: Administering oral medication can help to calm the client, but it may not be immediately effective if the client is already aggressive and out of control.
C. Call a family member or friend: Calling a family member or friend may provide emotional support, but it is not a direct intervention to address immediate physical aggression.
D. Apply restraints: When a client is physically aggressive and poses a risk of injury to themselves or others, applying restraints may be necessary to ensure safety. This should be done following proper protocols and as a last resort.
Correct Answer is A
Explanation
A. Neglect: Neglect is characterized by the failure to meet the basic needs of an individual, including food, shelter, clothing, and medical care. The signs of depression, underweight, and poor personal hygiene are consistent with neglect.
B. Emotional abuse: Emotional abuse involves behaviors that harm an individual’s self-worth or emotional well-being, such as name-calling, shaming, or isolating. While emotional abuse could be present, the physical signs of underweight and poor hygiene point more towards neglect.
C. Physical abuse: Physical abuse involves causing physical harm through actions such as hitting, slapping, or burning. There are no direct signs of physical trauma mentioned in the scenario, making physical abuse less likely.
D. Exploitation: Exploitation involves taking advantage of an individual for personal gain, often financially. The scenario does not provide information about financial or other forms of exploitation.
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