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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Chronic stress can weaken the immune system, making individuals more susceptible to infections, including viral infections. This is because stress hormones such as cortisol can suppress the immune response, making it harder for the body to fight off pathogens. As a result, individuals experiencing chronic stress may be more prone to illnesses such as the common cold or flu.
Incorrect:
A- Hypotension: Hypotension, or low blood pressure, is not typically associated with chronic stress. In fact, chronic stress often leads to increased sympathetic nervous system activity, which can result in elevated blood pressure.
C-Increased cognitive awareness: Chronic stress affects cognitive function. You might find it challenging to concentrate, make decisions, or stay mentally sharp.
D- Increased energy: Chronic stress typically leads to a state of exhaustion and fatigue rather than increased energy. Prolonged stress can drain a person's physical and mental energy, resulting in feelings of fatigue, lethargy, and a lack of motivation.
Correct Answer is D
Explanation
This response acknowledges the client's distress and invites them to share their thoughts and feelings about the situation. It shows empathy and demonstrates active listening, allowing the nurse to gather more information about the client's emotional state and concerns. By giving the client an opportunity to express themselves, the nurse can provide appropriate support and address any guilt or self-blame the client may be experiencing.
Dismissing the client's concerns and redirecting the conversation to their partner's condition (Option A) may invalidate the client's feelings and prevent them from processing their own emotions.
Telling the client to calm down (Option B) may come across as dismissive and insensitive.
Asking the client why they think the crash is their fault (Option C) may put the client on the defensive and hinder open communication. The best approach is to actively listen to the client's concerns and create a supportive environment for them to share their feelings.
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