A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

"Since you are trying to follow the treatment plan, we can submit your request to the provider."

"We are concerned about you and need to keep you safe."

"If you complete a contract that states you will not harm yourself, you can be alone."

"Until your medication has reached therapeutic levels, you will need constant observation."

Answer and Explanation

The Correct Answer is B

Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.

Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.

Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.

Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.

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Correct Answer is D

Explanation

Choice A reason: While verbalizing an improved mood is a positive outcome, it is not specific to borderline personality disorder and does not directly address the behavioral aspects of the condition.

Choice B reason: Hallucinations are not a typical symptom of borderline personality disorder; they are more commonly associated with psychotic disorders. Therefore, a decrease in hallucinations would not be a relevant treatment outcome for this condition.

Choice C reason:Encouraging personal hygiene supports general self-care but does not target the specific therapeutic goals for borderline personality disorder, which center on interpersonal effectiveness and emotion regulation.

Choice D reason: Teaching the client to articulate needs directly builds assertive communication and interpersonal effectiveness—core competencies in dialectical behavior therapy that reduce maladaptive behaviors and improve relationship stability.

A. "I will notify law enforcement within 2 hours if he cannot be found." B. "I will give his most recent photo to the police." C. "I will place a sliding bolt lock just above the doorknob." D. "I will ensure the bedroom is dark while he is sleeping at night."

Correct Answer is C

Explanation

Choice A reason: Notifying law enforcement within 2 hours if the person cannot be found is important, but immediate action is usually recommended in such cases. The sooner the authorities are alerted, the better the chances of locating the individual safely.

Choice B reason: Giving the most recent photo to the police is a proactive step in case the person goes missing. It can help law enforcement quickly disseminate the information and aid in the search. However, this is a reactive measure rather than a preventive one.

Choice C reason: Placing a sliding bolt lock just above the doorknob can prevent the individual from wandering, which is a common and dangerous issue in people with advanced Alzheimer's disease. This measure helps ensure the person's safety by preventing unsupervised exits from the home.

Choice D reason: Ensuring the bedroom is dark while the person is sleeping may not be advisable. Adequate night lighting is important for preventing falls if the person needs to get up during the night. A completely dark room can increase the risk of injury.

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A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has borderline personality disorder. Which of the following outcomes should the nurse include in the treatment plan?

Correct Answer is D

Explanation

A nurse is teaching the caregiver of a client who has advanced Alzheimer's disease about home safety. Which of the following statements by the caregiver indicates an understanding of the teaching?

Correct Answer is C

Explanation

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