A nurse is caring for a client who is experiencing suicidal thoughts.
Which of the following actions should the nurse take?.
Place the client on 12-hour observation.
Remove harmful objects from the client's room.
Encourage visitors for the client at any time.
Encourage visitors to bring items to the client.
The Correct Answer is B
Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
Correct Answer is D
Explanation
Choice A rationale:
Encouraging family to take the client out of the facility for short periods of time can be beneficial, but it does not address the sudden change in behavior.
Choice B rationale:
Rewarding the client for her change in behavior can reinforce positive behavior, but it does not address the sudden change in behavior.
Choice C rationale:
Asking the client why her behavior has changed can provide insight, but it does not ensure the safety of the client.
Choice D rationale:
Monitoring the client’s whereabouts at all times is important as a sudden change in mood can indicate a higher risk of suicide.
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