A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major 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 nursing interventions is appropriate?
Ask the client if she has a plan to commit suicide.
Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
Recognize the attempt at manipulation and escort the client back to her activity.
Assist the client to her room and allow her to rest before resuming activity.
The Correct Answer is A
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
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Correct Answer is D
Explanation
Choice A reason: Being honest is important in building a therapeutic relationship and can help the patient feel understood and respected.
Choice B reason: Developing trust is crucial for effective interventions and can encourage the patient to engage in treatment and share their feelings.
Choice C reason: Showing acceptance helps the patient feel safe and validated, which is essential in treating depression.
Choice D reason: Being judgmental is not an effective intervention as it can further alienate and discourage the patient, potentially worsening their condition.
Correct Answer is B
Explanation
Choice A reason: Interrupted electrical activity to areas of the heartWhen it comes to the pain associated with coronary artery disease (CAD), interrupted electrical activity is not the primary cause. While abnormal electrical activity can lead to arrhythmias, it is not the primary source of pain in CAD. The pain in CAD is primarily related to inadequate blood flow and oxygen supply to the heart muscle.
Choice B reason: Lack of sufficient oxygen to the myocardiumThis is the correct answer. Coronary artery disease results in the narrowing or blockage of coronary arteries, which supply oxygen-rich blood to the heart muscle. When these arteries become narrowed due to plaque buildup (atherosclerosis), the heart muscle does not receive enough oxygen. This insufficient oxygen supply leads to chest pain (angina) and discomfort.
Choice C reason: Increased cardiac workloadWhile increased cardiac workload can contribute to heart-related symptoms, it is not the primary cause of pain in coronary artery disease. Increased workload may occur during physical exertion or stress, but the underlying issue in CAD is the reduced blood flow due to narrowed or blocked arteries.
Choice D reason: Lack of nutrients into the heartWhile nutrients are essential for overall heart health, the primary concern in coronary artery disease is the lack of oxygen supply. The pain associated with CAD is primarily related to inadequate oxygen delivery to the heart muscle, not specifically a lack of nutrients.
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