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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Contains foods high in tyramine like avocado, ham, and chocolate cake.
B. Includes smoked sausage and yeast rolls which are high in tyramine
C. This meal consists of foods typically low in tyramine content, suitable for a tyramine- restricted diet.
D. Macaroni and cheese, hot dogs, and banana bread can contain high levels of tyramine
Correct Answer is C
Explanation
A. Verbally reporting to the psychiatrist might be appropriate but doesn’t directly address ensuring the safety of the potential victim.
B. Waiting for a court order might delay necessary action and put the potential victim at risk.
C. Ensuring the potential victim is warned is a crucial step to protect them from potential harm.
D. While confidentiality is important, the duty to protect potential victims supersedes confidentiality in cases of potential harm or danger.
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