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
This response acknowledges the client's feelings and respects their desire for space and silence. By offering to sit with the client, the nurse provides a comforting presence without pressuring the client to talk or share their emotions. It shows understanding and support for the client's current emotional state.
The other options may not be as helpful in this situation:
A- "Why are you feeling so down?" can be seen as intrusive and may make the client feel defensive or overwhelmed. It's important to respect the client's boundaries and not push them to explain their feelings if they are not ready.
B- "It might help you feel better if you talk about it." While talking about feelings can be beneficial for some individuals, it should be done on the client's terms. Pressuring the client to talk about their emotions may create additional distress.
C- "I understand. I've felt like that before, too." While sharing personal experiences can be a way to establish rapport, it should be done cautiously and with consideration for the client's unique situation. In this case, the focus should be on the client's needs rather than the nurse's experiences.
Correct Answer is A
Explanation
Anxiety and diaphoresis: Alcohol withdrawal commonly presents with symptoms of anxiety, restlessness, and excessive sweating (diaphoresis). These symptoms are due to the central nervous system's hyperactivity caused by the sudden cessation of alcohol intake.
Incorrect:
B- Muscle aches and chills: Muscle aches and chills are not typical manifestations of alcohol withdrawal. These symptoms are more commonly associated with opioid withdrawal rather than alcohol withdrawal.
C- Fatigue and depression: Fatigue and depression are common symptoms during alcohol withdrawal. The client may feel tired, lack energy, and experience a low mood due to the neurochemical imbalances that occur during withdrawal.
D- Arrhythmia and respiratory depression: While alcohol withdrawal can lead to some cardiovascular and respiratory symptoms, such as increased heart rate and blood pressure, severe arrhythmia and respiratory depression are not typical findings. These more severe symptoms may indicate a more severe withdrawal syndrome or coexisting medical conditions that require immediate medical attention.
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