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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.

Answer and Explanation

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.

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Correct Answer is ["A","E"]

Explanation

a. “I can see that you feel sad about this situation”.

e. “The loss of your parent should be very painful for you.”

These responses by the nurse show empathy and validate the patient’s feelings. They also encourage the patient to continue expressing their emotions and facilitate communication.

Option b. “Don’t be sad, everyone has to pass for something like this in the life” is not a helpful response

because it minimizes the patient’s feelings and may make them feel like their emotions are not valid.

Option c. “I felt very sad when my mother died, it was horrible!” is not a helpful response because it shifts the focus of the conversation away from the patient and onto the nurse’s personal experience.

Option d. “Let’s talk about something else. this subject is upsetting you, don’t worry about this” is not a helpful response because it dismisses the patient’s emotions and may make them feel like they are not allowed to express their feelings.

A. Suicidal or homicidal ideations B. Sleep patern changes C. Impulsive behaviours D. Only support systems

Correct Answer is A

Explanation

Borderline personality disorder is a serious mental illness characterized by instability in mood, behaviour, and self-image. Patients with borderline personality disorder are at a high risk of self-harm, suicide, and impulsive behaviours. Therefore, the nurse's priority assessment should be to identify any suicidal or homicidal ideations, as these can be life-threatening emergencies. Once identified, appropriate interventions should be initiated, such as suicide precautions, crisis management, and referral to mental health professionals for further evaluation and treatment.

While sleep patern changes, impulsive behaviours, and support systems are also important aspects to assess in patients with borderline personality disorder, they are not the priority when compared to suicidal or homicidal ideations.

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A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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. Select one or more:

Correct Answer is ["A","E"]

Explanation

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Correct Answer is A

Explanation

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