A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?
Initiating suicide precautions
Administering the Hamilton Depression Scale
Making a contract with the client for eating behavior
Reviewing the client's toxicology laboratory report
The Correct Answer is A
In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.
Incorrect:
B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.
C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.
D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This response demonstrates a therapeutic and empathetic approach to the client's distress. By offering to talk in a private area without interruption, the nurse provides the client with a safe space to express their feelings and concerns. It also allows the nurse to conduct a more in-depth assessment of the client's current emotional state and any specific triggers contributing to their anxiety.
A- Encouraging the client to lie down assumes that all clients with anxiety benefit from this approach, which may not be the case for everyone.
B- Simply suggesting medication may not address the underlying concerns or provide an opportunity for the client to express themselves.
C- While relaxation exercises can be beneficial for managing anxiety, suggesting them right away may not be the best response when the client is in a heightened state of distress.
Correct Answer is C
Explanation
Diazepam belongs to the benzodiazepine class of drugs and is commonly used to manage the symptoms of alcohol withdrawal. It helps alleviate anxiety, agitation, tremors, and seizures that can occur during alcohol withdrawal. Diazepam has sedative effects and helps prevent and treat alcohol withdrawal seizures by acting on the central nervous system.
Incorrect:
A- Disulfiram is a medication used to support alcohol abstinence by creating unpleasant reactions if alcohol is consumed. It is not typically administered during acute alcohol withdrawal.
B- Naltrexone is used to help individuals with alcohol dependence reduce their alcohol cravings and drinking behavior. It is not typically used during the acute phase of alcohol withdrawal.
D- Acamprosate is a medication used to maintain abstinence from alcohol in individuals who have already stopped drinking. It is not typically used during the acute phase of alcohol withdrawal.
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