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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. It indicates a positive childhood experience where the adolescent has a supportive and attentive teacher who listens well. Positive relationships with supportive adults, such as teachers, coaches, or mentors, can serve as protective factors for adolescents with anxiety disorders
A. This statement suggests that the adolescent experiences stress and worry related to their sibling's health problems, which may exacerbate their anxiety rather than serving as a protective factor.
B. This statement provides information about the adolescent's family background but does not necessarily indicate a positive childhood experience or protective factor for anxiety.
D. Frequent moves associated with military life may present challenges rather than protective factors for anxiety, such as disruptions in social relationships and support networks.
Correct Answer is C
Explanation
C. The nurse should address the client's inappropriate and boundary-crossing behavior first. The client's statement, "Kiss me baby! You know you want to!" is suggestive and inappropriate in a professional healthcare setting. It indicates a lack of understanding or disregard for appropriate social boundaries and may be a manifestation of the client's serious mental illness.
A, B, D- While the client's vital signs (blood pressure, heart rate, respiratory rate, and temperature) and clothing choice (wearing a heavy coat and scarf in warm weather) may be important to assess and address, the immediate priority is to address the client's inappropriate behavior and ensure a safe and therapeutic environment for both the client and the nurse.
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