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?

Administering the Hamilton Depression Scale.

Making a contract with the client for eating behavior.

Reviewing the client's toxicology laboratory report.

Initiating one to one continuous observation.

Answer and Explanation

The Correct Answer is D

Administering the Hamilton Depression Scale is a tool used to assess the severity of depression. While it can provide valuable information about the client's mental state, it is not the priority intervention in this case. The client has already attempted suicide, indicating a high level of risk. It is essential to focus on ensuring the client's immediate safety before conducting further assessments.

Rationale for Choice B:

Making a contract with the client for eating behavior can be a helpful intervention for clients with anorexia nervosa. However, it is not the priority in the immediate aftermath of a suicide attempt. The client's safety must take precedence over addressing their eating disorder.

Rationale for Choice C:

Reviewing the client's toxicology laboratory report can provide information about the substances the client ingested in their suicide attempt. However, this information is not necessary for determining the immediate course of action. The priority is to initiate safety measures to prevent another attempt.

Rationale for Choice D:

Initiating one-to-one continuous observation is the most critical intervention for a client who has recently attempted suicide. This level of observation ensures that the client is constantly monitored and cannot make another attempt without being interrupted. It also allows the nurse to assess the client's mental state and behaviors closely and intervene if necessary.

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Correct Answer is B

Explanation

Choice A rationale:

Avoids addressing the client's behavior: This response does not directly address the client's disrespectful tone of voice. It simply gives the client the schedule and expects them to comply. This could reinforce the client's belief that they can act out without consequences.

Misses an opportunity to set boundaries: Setting boundaries is essential when working with clients with BPD. This response does not establish a clear boundary regarding acceptable communication.

Does not promote therapeutic communication: This response does not encourage the client to share their feelings or explore the reasons behind their outburst. It shuts down communication rather than opening it up.

Choice B rationale:

Directly addresses the inappropriate behavior: This response assertively communicates to the client that their tone of voice is unacceptable. It sets a clear boundary regarding respectful communication.

Models appropriate communication: The nurse models respectful communication by using a calm and assertive tone of voice. This can help the client learn to communicate more effectively.

Promotes self-awareness: This response may prompt the client to reflect on their behavior and the impact it has on others. It can help them develop better self-awareness and emotional regulation skills.

Choice C rationale:

Focuses on the nurse's feelings: This response shifts the focus away from the client's behavior and onto the nurse's feelings. It can make the client feel defensive and less likely to engage in productive communication.

May escalate the situation: Asking "why" s can sometimes put clients on the defensive and lead to further conflict. It's generally more helpful to focus on the present behavior and its impact.

Choice D rationale:

Condescending and challenging: This response comes across as condescending and challenging. It's likely to make the client feel defensive and resentful.

Not therapeutic: This response does not promote a sense of trust or rapport between the nurse and the client. It's unlikely to lead to productive communication or behavior change.

A. Walk with the client at a gradually slower pace. B. Have a staff member escort the client to her room. C. Allow the client to pace alone until physically tired. D. Instruct the client to sit down and stop pacing.

Correct Answer is A

Explanation

Rationale for Choice A:

Pacing can be a physical manifestation of anxiety. It allows individuals to release some of the nervous energy that builds up during anxious moments. Restricting this behavior can potentially escalate anxiety.

Walking with the client can provide a sense of safety and support. It demonstrates to the client that they are not alone in their anxiety and that the nurse is there to help them.

Gradually slowing the pace of the walk can help to regulate the client's breathing and heart rate. This can have a calming effect on both the body and mind.

Walking can also be a form of distraction. It can help to take the client's mind off of their worries and focus on the present moment.

Walking can help to release endorphins, which have mood-boosting effects. This can help to counteract some of the negative emotions associated with anxiety.

Rationale for Choice B:

Escorting the client to their room may be perceived as restrictive and controlling. This could potentially increase the client's anxiety.

Removing the client from the public area of the unit may isolate them from other people and activities. This could make them feel more alone and anxious.

Rationale for Choice C:

Allowing the client to pace alone may not be safe. The client could potentially become agitated or injure themselves.

Pacing alone does not provide the client with any support or guidance. This could make it more difficult for them to manage their anxiety.

Rationale for Choice D:

Instructing the client to sit down and stop pacing may be perceived as dismissive and unhelpful. It does not address the underlying causes of the client's anxiety.

Forcing the client to stop pacing could potentially escalate their anxiety. This could lead to agitation, aggression, or other negative behaviors.

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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?

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Correct Answer is B

Explanation

A mental health nurse on a mental health unit is caring for a client who has generalized anxiety disorder (GAD). The client received a telephone call that was upsetting, and now the client is pacing up and down the corridors of the unit.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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?