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

Answer and Explanation

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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Correct Answer is D

Explanation

Remaining with the client demonstrates a supportive and therapeutic presence. It can help provide a sense of safety, reassurance, and comfort to the client who is experiencing difficulty sleeping and exhibiting signs of anxiety or restlessness. By staying with the client, the nurse can actively listen, observe, and assess the client's needs, allowing for prompt intervention if necessary.

A- Giving a PRN (as-needed) sleeping medication should not be the first response, as it is important to explore non-pharmacological interventions and address the underlying cause of the client's difficulty sleeping.

B- Exploring alternatives to pacing the floor with the client may be an appropriate intervention after assessing the client's needs and preferences.

C- Encouraging the client to go back to bed may not be effective if the client is experiencing significant anxiety or restlessness.

A. Recognizing the warning signs of suicide B. Identifying individuals who are at higher risk for attempting suicide C. Performing life-saving measures following a suicide attempt D. Providing support for family and friends following a suicide

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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