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

Explanation

Rationale for A: Inviting a family member to be present may hinder communication, especially if the family member is involved in the abuse or the client feels unsafe speaking in their presence. Privacy is crucial for encouraging open communication.

Rationale for B: Providing basic wound care is important for physical injuries, but it does not directly address promoting communication. The nurse should focus on creating a safe environment for the client to talk.

Rationale for C: Being direct and honest when speaking with the client promotes trust and open communication. Clients who are suspected of being abused may be fearful or reluctant to share information, so clear, respectful communication helps create a supportive environment.

Rationale for D: Probing the client for a factual account of the abuse may make the client feel pressured or overwhelmed. The nurse should allow the client to share information at their own pace without feeling forced to disclose details.

A. Identifying the client's coping skills B. Determining if the client has psychotic thinking C. Identifying the client's support systems D. Asking the client to identify the cause of the crisis

Correct Answer is B

Explanation

A. While assessing coping skills is essential, in a crisis situation, determining immediate risks to the client's safety takes precedence.
B. Assessing for psychotic thinking is crucial to address immediate safety concerns. Psychosis can present significant risks and requires immediate attention.
C. While support systems are important for long-term recovery, determining immediate safety concerns is a priority.
D. Identifying the cause of the crisis is relevant but may not be the immediate priority when the client's safety is at risk due to potential psychotic thinking.

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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

A nurse is caring for a client who was admitted for suspected abuse. The client is quiet and withdrawn. Which of the following actions should the nurse take to promote client communication?

Correct Answer is C

Explanation

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

Correct Answer is B

Explanation

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

A client has made a successful suicide attempt while hospitalized on a unit that specializes in the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement?

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? (Select all that apply.)

A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

An individual has been diagnosed with a dissociative disorder. Which comorbid psychiatric disorders are most likely to accompany this type of mental illness? (Select all that apply.)

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?