A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Explain to the client that self-harm behaviors do not increase their risk for accidental death.

Inform the client that self-harm behavior cannot become a serious problem in the future.

Encourage the client to identify the emotions they feel immediately before performing the self- harm behavior.

Place the client in one-on-one direct observation due to overt suicidal intent.

Answer and Explanation

The Correct Answer is C

C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.

A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.

B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress

D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.

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Correct Answer is B

Explanation

A. While it's important to gather relevant information about the assault, asking open-ended questions about the perpetrator may not be the most appropriate approach initially.

B. Speaking softly helps to convey empathy and can make the client feel more comfortable and less threatened.

C. Direct eye contact can be perceived as intrusive or threatening, especially for individuals who have experienced trauma such as sexual assault.

D. Sitting next to the client rather than directly across can create a more relaxed and less intimidating atmosphere. This approach can help establish a sense of partnership and support, making the client feel more at ease.

A. Lack of emotions B. Paranoia C. Confusion D. Distorted beliefs

Correct Answer is A

Explanation

A. A lack of emotions, also known as flat affect or emotional blunting, is a common negative symptom of schizophrenia. It refers to a reduced range or intensity of emotional expression, such as reduced facial expressions, tone of voice, or gestures.

B. Paranoia is not a negative symptom but rather a positive symptom of schizophrenia.

C. Confusion may occur in schizophrenia, but it is not specific to negative symptoms. Confusion can be a result of various factors, including medication side effects, acute psychosis, or cognitive deficits.

D. Distorted beliefs, such as delusions, are considered positive symptoms rather than negative symptoms of schizophrenia.

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A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

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