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 B

Explanation

A. While impulsive actions can contribute to suicide, it doesn't specifically relate to monitoring during antidepressant therapy.
B. Monitoring is crucial because as depressive symptoms improve, the energy levels may increase before mood stabilizes, potentially increasing the risk of acting on suicidal thoughts.
C. While true, this statement doesn't specifically address the need for monitoring during antidepressant therapy.
D. This statement highlights a potential issue for suicidal patients but doesn't directly relate to the need for monitoring during antidepressant therapy.

A. Call for assistance to place the client in restraints. B. Escort the client to an unlocked seclusion room. C. Speak to the client calmly, giving simple directions. D. Offer the client a PRN antianxiety medication.

Correct Answer is C

Explanation

A. Restraining the client should be a last resort and is not the initial action to take when managing an agitated client.
B. Seclusion should also be considered as a last resort, and de-escalation techniques should be attempted before secluding the client.
C. Speaking calmly and providing simple directions can help de-escalate the situation by promoting a calm environment and reducing stimuli that may exacerbate the client's agitation.
D. While medication might be necessary in some cases, it's not the first action to take when a client becomes agitated.

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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 statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?

Correct Answer is B

Explanation

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

The decision to intervene as a patient advocate is clearly identified by the American Nurses Association's (ANA) code of ethics in which situation?

Which institution-specific clinical practice resource will the nurse use to integrate evidence- based practice (EBP) into the care of a client hospitalized for the purpose of the evaluation of his or her current therapy plan?

A nurse is discussing the process of evidence-based practice (EBP) with a newly licensed nurse. Which of the following statements made by the newly licensed nurse indicates an understanding of the process?

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?

A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? (Select all that apply.)

A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

A nurse is caring for a client who was involved in heavy combat and observed war casualties. The nurse should suspect that the client is suffering from posttraumatic stress disorder (PTSD) if the client makes which of the following statements?