A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
Initiate one to one constant supervision around the clock.
Ensure the client's hands are always visible.
Tuck bedcovers over client's hands and arms.
Inspect the client's personal belongings.
Check the environment for possible hazards.
Assign the client to a private room.
Place only plastic utensils on the client's meal tray.
Correct Answer : A,E
a. Initiate one to one constant supervision around the clock: A client who has attempted suicide is at high risk for further harm, and close monitoring is necessary to prevent further attempts. Initiation of one-to- one constant supervision around the clock ensures that the client is continuously monitored, and any signs of suicidal ideation or behavior can be immediately addressed.
e. Check the environment for possible hazards: It is important to check the client's environment for potential hazards, such as sharp objects, cords, or other items that could be used to harm oneself. This step helps to ensure the client's safety and prevent further attempts.
The other options are not appropriate or necessary in this situation:
b. Ensure the client's hands are always visible: This action may be necessary if the client has a history of self-harm or aggressive behavior, but it is not specifically related to preventing suicide attempts.
c. Tuck bedcovers over client's hands and arms: This action may be necessary if the client has a history of self-harm, but it is not specifically related to preventing suicide attempts.
d. Inspect the client's personal belongings: While it may be important to inspect the client's personal belongings for any items that could be used for self-harm, this action is not as urgent as initiating constant supervision and checking the environment for hazards.
f. Assign the client to a private room: While a private room may be beneficial for the client's comfort and privacy, it is not specifically related to preventing suicide attempts.
g. Place only plastic utensils on the client's meal tray: This action is not specifically related to preventing suicide attempts, unless there is concern that the client may harm themselves with utensils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Therapeutic communication involves actively listening to the client, demonstrating empathy, and using open-ended questions to encourage the client to express their thoughts and feelings.
Reflecting (option a) and listening attentively (option b) are both examples of effective therapeutic communication techniques as they demonstrate active listening and empathy.
However, offering advice (option c) is a barrier to therapeutic communication because it implies that the nurse knows what is best for the client and can solve their problems for them.
This can create a power dynamic in the nurse-client relationship and may discourage the client from expressing their true thoughts and feelings. Giving information (option d) can be an important aspect of therapeutic communication, but it should be done in a way that respects the client's autonomy and involves collaboration rather than giving directives.
Correct Answer is A
Explanation
Cognitive therapy is a type of psychotherapy that focuses on identifying and changing negative thought patterns and beliefs that contribute to psychological distress. In this case, the single parent is experiencing feelings of inadequacy related to work and family since one teenaged child ran away 2 weeks ago. The cognitive therapist would work with the client to identify any negative or distorted thoughts they may be having about themselves, their situation, and their ability to cope.
Through cognitive therapy, the therapist would help the client learn how to challenge and change their negative thoughts and beliefs, replacing them with more realistic and positive ones. The goal of cognitive therapy is to help the client develop new coping skills and ways of thinking that will enable them to better manage their emotions and improve their overall well-being.
Option b, negatively reinforcing an undesirable behavior every day to avoid it, is not a component of cognitive therapy. This approach is more aligned with behavioral therapy, which focuses on modifying behaviors through reinforcement and punishment.
Option c, focusing on conscious mental processes, is partially correct, as cognitive therapy does focus on conscious mental processes. However, this alone does not fully capture the essence of cognitive therapy.
Option d, always discussing Freud ego stages, is not relevant to cognitive therapy, as it is a psychoanalytic approach developed by Freud that focuses on the unconscious mind and early childhood experiences.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today