A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Recognize the attempt at manipulation and escort the client back to her activity.

Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.

Ask the client if she has a plan to commit suicide.

Assist the client to her room and allow her to rest before resuming activity.

Answer and Explanation

The Correct Answer is C

A.   Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B.   While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C.   Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D.   The situation requires more immediate assessment and action due to the expressed suicidal ideation.

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Correct Answer is ["C","D"]

Explanation

A. Discussing the client's suicide plan might inadvertently trigger or worsen suicidal thoughts and is not recommended.
B. Restricting visitors might hinder the client's social support system, which is essential in managing depression.
C. Reinforcing statements regarding a will to live and realistic plans for the future promotes hope and positive thinking.
D. Encouraging the client to discuss thoughts and feelings about wanting to die allows for expression and processing of emotions.
E. Limiting time allowed to play video games might be part of a broader plan, but it's not directly addressing depression and might not be as impactful as other interventions.

A. "Oh, I'm so pleased that you finally put on clean clothes." B. "Why did your wear clean clothes and comb your hair today?" C. “I see that you have on clean clothes and have combed your hair." D. "Your mood must be lifting because you have on clean clothes and have combed your hair."

Correct Answer is C

Explanation

A. This response may convey a sense of judgment or imply the client's previous state was unacceptable, potentially making the client feel criticized.
B. This question might inadvertently put the client on the defensive and seems intrusive, possibly making the client uncomfortable.
C. This response is observational and nonjudgmental, acknowledging the change without implying any criticism.
D. This response assumes the reason for the change without allowing the client to express herself and might not accurately reflect the client's emotional state or motivation.

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A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

Correct Answer is C

Explanation

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