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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Respiratory depression/arrest is a well-documented risk associated with heroin use. Heroin is an opioid that can significantly depress the central nervous system, leading to slowed or stopped breathing. This can result in hypoxia, a condition where not enough oxygen reaches the brain, which can be fatal.
Choice B reason:
Acute pancreatitis is not typically associated directly with heroin use. While substance use can lead to various health complications, acute pancreatitis is more commonly associated with alcohol abuse rather than opioids like heroin.
Choice C reason:
Nasal septum perforation is a potential risk for individuals who snort heroin. The repeated irritation and damage to the mucosal tissues in the nose can lead to a perforation of the nasal septum, the tissue that separates the nasal passages.
Choice D reason:
Permanent short-term memory loss is not a commonly reported direct effect of heroin use. While chronic use of heroin can lead to cognitive deficits and deterioration of white matter in the brain, which affects decision-making and behavior regulation, it does not specifically cause permanent short-term memory loss.
Correct Answer is A
Explanation
Choice A reason:
Walking with the client at a gradually slower pace is a therapeutic technique that can help reduce anxiety. It allows the nurse to provide a calming presence and support while also helping to decrease the client's physical agitation in a controlled manner. This approach is non-confrontational and can be very effective in managing acute anxiety symptoms.
Choice B reason:
Having a staff member escort the client to her room might seem like a reasonable option, but it could be perceived as punitive or isolating, especially if the client is not posing a risk to themselves or others. It may also escalate the client's anxiety by making them feel confined or punished.
Choice C reason:
Instructing the client to sit down and stop pacing is not advisable as it may come across as dismissive of the client's distress. It could also increase the client's anxiety by making them feel that their coping mechanism (pacing) is not acceptable, which could lead to increased agitation or resistance.
Choice D reason:
Allowing the client to pace alone until physically tired is not the best option as it does not provide any direct support or intervention from the nurse. While pacing may be a self-soothing behavior, it does not address the underlying anxiety and could potentially lead to physical exhaustion without any emotional relief.
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