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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A Reason:
In a situation where a client has ingested a potentially lethal amount of medication, immediate medical intervention is crucial. Amitriptyline is a tricyclic antidepressant, and overdose can lead to life-threatening conditions such as cardiac arrhythmias, severe hypotension, and seizures. The nurse's priority is to ensure the safety of the client by sending an ambulance. This response also acknowledges the client's cry for help and initiates prompt action.

Choice B Reason:
While it's important to recognize the emotional state of the client, this response does not address the immediate medical emergency. The client's safety is the priority, and while their feelings are valid, this choice does not facilitate the urgent care needed.

Choice C Reason:
Asking if the client was trying to commit suicide can come across as judgmental and may close off communication. It's essential to maintain an open line of communication and focus on getting medical help rather than determining intent at this critical moment.

Choice D Reason:
Knowing the quantity of medication ingested can be useful information for medical professionals; however, it is not the most immediate concern in a crisis situation. The first response should be to ensure that medical help is on its way.

A. "I can't call a doctor in the middle of the night unless it's an emergency." B. "You must be very upset about something." C. "Go back to your room, and I'll try to get in touch with your doctor." D. "You are being unreasonable, and I will not call your doctor at this hour."

Correct Answer is B

Explanation

Choice A: "I can't call a doctor in the middle of the night unless it's an emergency."
This response may seem reasonable, but it could escalate the situation if the client feels their concerns are not being taken seriously. It's important to validate the client's feelings and find a solution that respects both their needs and the realities of the situation.

Choice B: "You must be very upset about something."
This response validates the client's feelings and opens up a dialogue. It shows empathy and understanding, which can help de-escalate the situation.

Choice C: "Go back to your room, and I'll try to get in touch with your doctor."
This response acknowledges the client's request and provides a clear action plan. However, it's important to follow through on this promise to maintain trust.

Choice D: "You are being unreasonable, and I will not call your doctor at this hour."
This response is confrontational and likely to escalate the situation. It's important to remain calm and professional, even when dealing with difficult behavior.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse who works in a psychiatric unit is caring for a client diagnosed with bipolar disorder. The client comes to the nurse's station at 0300, demanding that the nurse call the provider immediately. Which of the following responses should be an appropriate response by the nurse?

Correct Answer is B

Explanation

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