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 D
Explanation
Informed consent is an essential ethical principle in healthcare, including mental health treatment. Even if the client has previously signed a consent form for electroconvulsive therapy (ECT), they have the right to change their mind and refuse the treatment at anytime. Respecting the client's autonomy and their right to make decisions about their own healthcare is crucial.
The nurse's response should support the client's right to refuse the treatment, rather than attempting to persuade or convince them otherwise. It is important to provide information, answer questions, and discuss the client's concerns or reasons for refusing the treatment. The client's decision should be respected and further discussions can be held with the healthcare provider to explore alternative treatment options or address any concerns the client may have.
A- "You have given signed consent for the treatments after they were explained to you." - This response does not acknowledge the client's right to refuse the treatment. Even if the client previously provided consent, they still have the right to change their mind and refuse the treatment. Informed consent is an ongoing process, and the client's autonomy should be respected throughout their care.
B- "You can refuse them, but the provider believes they are necessary." - While it may be true that the healthcare provider believes ECT is necessary, this response does not fully acknowledge the client's autonomy. It is important to emphasize the client's right to make decisions about their own healthcare, independent of the provider's opinion. The decision to refuse or accept the treatment should ultimately be made by the client.
C- "You will feel better after the course of treatments." - This response does not address the client's concerns or their right to refuse the treatment. It is essential to respect the client's autonomy and their ability to make decisions about their own care, even if their decision may not align with the potential benefits of the treatment. The nurse should focus on providing information, addressing the client's concerns, and supporting their decision-making process.
Correct Answer is C
Explanation
Secondary interventions are aimed at reducing the harm or preventing further complications in individuals who have already engaged in suicidal behavior. In this case, performing life-saving measures after a suicide attempt, such as cardiopulmonary resuscitation (CPR) or administering first aid, falls under the category of secondary intervention.
The other options are examples of primary and tertiary interventions:
A- Recognizing the warning signs of suicide: This is an example of primary intervention, which focuses on preventing suicidal behavior before it occurs by raising awareness, promoting mental health, and identifying risk factors and warning signs.
B- Identifying individuals who are at higher risk for attempting suicide: This is also an example of primary intervention, as it involves assessing and identifying individuals who may be at greater risk for suicidal behavior and implementing preventive measures.
D- Providing support for family and friends following a suicide: This is an example of tertiary intervention, which aims to provide support and care to those who have been affected by a suicide, including family and friends. Tertiary interventions focus on postvention, addressing the aftermath and providing support for survivors.
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