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.
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Related Questions
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.
Correct Answer is B
Explanation
A. While both schizophrenia and PTSD are mental health disorders, the priority in this context for a soldier with a history of combat exposure is to screen for conditions that commonly arise from traumatic experiences, such as PTSD and major depressive disorder.
B. PTSD and major depressive disorder can often co-occur, especially in individuals exposed to trauma. Given the soldier's history of combat exposure and PTSD diagnosis, screening for major depressive disorder is crucial due to its frequent association with PTSD and its potential severity.
C. Bipolar disorder may share some symptoms with PTSD, but given the context of returning from combat and the diagnosis of PTSD, the priority would be to focus on screening for
conditions more directly linked to trauma.
D. Dementia is less likely to be directly related to combat exposure in a returning soldier. While it's essential to assess the soldier's overall mental health, the immediate concern in this scenario would be mental health conditions more commonly associated with trauma.
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