A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?
"Can you tell me about the stresses in your life?"
"Has anyone in your family ever died by suicide?
“Do you have a plan for harming yourself?"
“Do you have someone to discuss your feelings with?"
The Correct Answer is C
Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.
While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.
The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.
Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Overhearing a discussion about a client's private information is a breach of confidentiality, and it is the nurse's responsibility to address the situation promptly.
While documenting the event in the client's progress notes might be necessary in some cases, it is not the initial action to take in this scenario. Similarly, submitting an incident report to the risk manager may be required for documentation purposes, but it is not the immediate action to address the breach of confidentiality.
Informing the client of the APs' actions may not be necessary unless there is evidence that the client's privacy has been compromised or if the client specifically requests to know. However, the priority is to address the issue of the conversation between the APs and ensure that confidentiality is maintained.
Correct Answer is D
Explanation
Range-of-motion exercises are within the scope of practice for an AP and do not require specialized nursing knowledge or assessment skills. The AP can assist the client in performing these exercises to promote circulation, maintain joint mobility, and prevent complications associated with immobilization.
Determining the circulation status of the affected extremities, evaluating the need for restraints, and providing education to the client's family about the purpose of restraints require nursing assessment, critical thinking, and communication skills. These tasks should be performed by a licensed nurse who can make clinical judgments and ensure the safety and well-being of the client.
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