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.
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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Related Questions
Correct Answer is D
Explanation
D. In the immediate aftermath of a sexual assault, the primary focus of the SANE nurse is to ensure the safety and well-being of the client. This includes providing a safe and supportive environment for the client, assessing and treating any physical injuries, addressing immediate medical needs, and offering emotional support and crisis intervention.
A, B, and C involve aspects of legal procedures and involvement of law enforcement, but they may not be appropriate or feasible for every client in every situation. Additionally, the decision to involve law enforcement or pursue legal action should be made in collaboration with the client and should prioritize their safety, autonomy, and well-being.
Correct Answer is C
Explanation
C. Calling the poison control center is the immediate and most important action to take in cases of potential poisoning or chemical exposure. Poison control centers have trained professionals who can provide immediate guidance on how to assess the situation, provide first aid if necessary, and determine if further medical evaluation or treatment is needed.
A. While assessing the parent's understanding of emergency measures is important, it may not be the first action to take in this situation.
B. Providing information about the risks of chemical exposure can be helpful for prevention, but it may not be the first action to take when there is uncertainty about whether the child has ingested a harmful substance.
D. While securing cleaning supplies to prevent future incidents is important, it is not the first action to take when there is concern about a potential ingestion.
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