A nurse is caring for a client three days after admission for treatment of depression. The client leaves her current activity, approaches the nurse, and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?
Ask the client if she has a plan to commit suicide.
Assist the client to her room and allow her to rest before resuming activity.
Recognize the attempt at manipulation and escort the client back to her activity.
Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
The Correct Answer is A
Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.
Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.
Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.
Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Decreasing the dose of Xanax (alprazolam) is often necessary when a client shows signs of dependency or when there are concerns about potential side effects, such as uncontrolled hypertension. Xanax is a fast-acting benzodiazepine, which can be highly addictive, especially when taken in doses of 4 mg/day for longer than 12 weeks. It is essential to monitor the client's blood pressure and adjust the medication accordingly to avoid exacerbating hypertension.
Choice B reason:
Increasing the dose may temporarily control symptoms of anxiety, but it also increases the risk of dependency and other side effects. Given the client's uncontrolled hypertension, increasing the dose could lead to further complications.
Choice C reason:
This statement is incorrect. Xanax does cause dependency, and it is one of the most addictive benzodiazepine medications on the market today. Dependency can develop quickly, even in users who follow a prescribed dosing schedule.
Choice D reason:
While Ativan (Lorazepam) is also used to treat anxiety, adding it to the client's medication regimen without careful consideration could increase the risk of dependency and adverse effects. Both Xanax and Ativan are benzodiazepines, and their combined use should be monitored closely by a healthcare professional.
Correct Answer is B
Explanation
Choice A: Turn on a dance video so the client can burn off excess energy.
This intervention might help the client to channel their energy in a safe and controlled manner. However, it might also reinforce the manic behavior, which could be counterproductive in the long term.
Choice B: Take the client to a calm environment and offer snacks.
This intervention could help to distract the client from their manic behavior and provide them with a calming and grounding experience. Offering snacks could also help to stabilize their energy levels.
Choice C: Offer the client a low-calorie snack in return for stopping the behavior.
This intervention could be seen as a form of behavioral reinforcement. However, it might not be effective if the client is not motivated by food or if they perceive it as a form of manipulation.
Choice D: Observe the client closely for the development of aggressive behavior.
This intervention is crucial for ensuring the safety of the client and others in the unit. If the client's behavior escalates to aggression, the nurse would need to take immediate steps to de-escalate the situation and protect everyone involved.
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