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: Providing reassurance and comfort through touch can be beneficial in some cases; however, for clients experiencing command hallucinations, physical touch may be misinterpreted and could potentially escalate the situation. It's essential to gauge the client's comfort level with touch and proceed cautiously.

Choice B reason: While socialization is an important aspect of recovery, for a client experiencing command hallucinations, group therapy might be overwhelming and could exacerbate the hallucinations. It's crucial to introduce socialization gradually and in a controlled environment.

Choice C reason: Eye contact can be perceived as threatening or confrontational by clients with schizophrenia, especially when experiencing command hallucinations. It's important to respect the client's space and use non-confrontational body language to communicate effectively.

Choice D reason: Maintaining a low level of environmental stimuli is crucial for clients experiencing command hallucinations. A calm and quiet environment can help reduce the intensity and frequency of hallucinations, providing a sense of safety and reducing stress and anxiety.

A. "These symptoms will improve over time." B. "You will need to have your blood drawn." C. "You should decrease your intake of sodium." D. "Continue the medication as prescribed."

Correct Answer is B

Explanation

Choice A reason: Telling the client that the symptoms will improve over time without further assessment could be misleading. These symptoms could indicate lithium toxicity, which requires immediate medical attention.

Choice B reason: Lethargy, muscle weakness, and blurred vision can be signs of lithium toxicity. The nurse should recommend blood tests to check lithium levels and kidney function to rule out toxicity.

Choice C reason: Decreasing sodium intake is not recommended without a healthcare provider's advice, as sodium levels can affect lithium levels in the body. Sudden changes in sodium intake should be avoided unless directed by a healthcare provider.

Choice D reason: Continuing the medication as prescribed without addressing the symptoms could be dangerous. The symptoms reported by the client need to be evaluated to ensure they are not due to lithium toxicity.

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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

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Correct Answer is D

Explanation

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Explanation

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