A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Implement continuous one-to-one observation.
Encourage the client to participate in group therapy.
Ask the client to sign a no-suicide contract.
Establish a rapport to foster trust.
The Correct Answer is A
The correct answer is:
A. Implement continuous one-to-one observation.
Choice A reason:
Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.
Choice B reason:
While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.
Choice C reason:
Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.
Choice D reason:
Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.
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Related Questions
Correct Answer is C
Explanation
Methadone is a medication-assisted treatment (MAT) option for clients who have opioid use disorder. Methadone reduces withdrawal symptoms and cravings, and blocks the effects of other opioids. Methadone is dispensed through specialized clinics that have strict policies and regulations to ensure safety and compliance. The nurse should inform the client about these policies, such as the frequency of visits, urine testing, and counseling requirements, and help the client enroll in a methadone program if they are interested. The other options are not appropriate for this client. The CAGE questionnaire is a screening tool for alcohol use disorder, not opioid use disorder. Varenicline is a medication used to help clients quit smoking, not opioids. Emergency commitment is a legal process that allows involuntary hospitalization of clients who pose a danger to themselves or others due to a mental illness, which does not apply to this client.
Correct Answer is C
Explanation
This question helps the nurse to evaluate the client's personal coping skills and identify their strengths and weaknesses. Asking about the impact of the situation, the current feelings, or the future outlook are not directly related to coping skills, although they might provide some useful information.
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