A nurse on an inpatient mental health unit is reinforcing teaching to a newly licensed nurse about suicide prevention. Which of the following statements made by the newly licensed nurse indicates an understanding of the information?
"The blinds in the client's room will need to stay closed to prevent overstimulation."
"Family members should be encouraged to look up the warning signs of suicide."
"The client can eat their meal alone in their room."
"All sharp objects should be removed from the client's room."
The Correct Answer is D
A. The blinds in the client's room will need to stay closed to prevent overstimulation. Keeping the blinds closed is not a standard suicide prevention measure. While reducing overstimulation may be helpful for some mental health conditions, suicide prevention focuses more on removing means of self-harm, increasing supervision, and providing therapeutic interventions.
B. Family members should be encouraged to look up the warning signs of suicide. While educating family members about suicide warning signs is beneficial, simply encouraging them to look up the information is insufficient. The nurse should provide direct education and resources to ensure they recognize signs of suicidal ideation and know how to respond appropriately.
C. The client can eat their meal alone in their room. Allowing a suicidal client to eat alone increases the risk of self-harm, as food-related items (such as utensils, plastic bags, or containers) could be misused. Clients at risk for suicide should be supervised during meals to ensure their safety.
D. All sharp objects should be removed from the client's room. Removing sharp objects is a critical component of suicide prevention in inpatient settings. Limiting access to potential means of self-harm, including sharp items, cords, belts, and other dangerous objects, helps reduce the risk of suicide attempts.
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Related Questions
Correct Answer is C
Explanation
A. Lithium toxicity. The AIMS test does not assess lithium toxicity. Lithium toxicity is monitored through serum lithium levels and clinical symptoms such as tremors, nausea, confusion, and ataxia. Severe toxicity can lead to seizures, coma, and organ failure, requiring immediate intervention.
B. Alcohol withdrawal. The AIMS test does not assess alcohol withdrawal. Withdrawal symptoms include tremors, hallucinations, seizures, and autonomic instability. The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) is commonly used to assess symptom severity and guide treatment.
C. Tardive dyskinesia. The AIMS test is used to assess tardive dyskinesia, a movement disorder caused by long-term antipsychotic use. It evaluates involuntary movements of the face, tongue, and extremities, helping clinicians monitor progression and adjust medications to minimize symptoms.
D. Opiate withdrawal. The AIMS test does not assess opiate withdrawal. Symptoms include sweating, agitation, diarrhea, and muscle aches. The Clinical Opiate Withdrawal Scale (COWS) is typically used to assess withdrawal severity and guide opioid detoxification or replacement therapy.
Correct Answer is C
Explanation
A. "When attending dialectical behavior therapy." Dialectical behavior therapy (DBT) is specifically designed to help individuals with borderline personality disorder (BPD) manage emotions and reduce self-harming behaviors. While therapy can bring up distressing emotions, it provides structured support and coping strategies. The risk of self-harm is lower when clients are actively engaged in treatment and receiving professional guidance.
B. "When getting married." Major life changes, including marriage, can be stressful for individuals with BPD, but they do not inherently pose the highest risk for self-harm. Support from a partner and structured therapy can help navigate emotional challenges. While instability in relationships can trigger distress, the protective factors of marriage may reduce immediate risk. Self-harm risk is typically higher in periods of transition without support.
C. "When discharged from the hospital." Clients with BPD often struggle with emotional regulation, and discharge represents a significant transition with decreased support. The sudden loss of a structured inpatient setting can increase feelings of abandonment and distress, leading to a heightened risk of self-harm. Ensuring a follow-up care plan and support system is crucial to reducing this risk after hospitalization.
D. "When attending narrative therapy." Narrative therapy helps clients reframe their experiences and build a stronger sense of identity. Although deep emotional topics may be explored, structured therapy provides a safe space for expression. Therapeutic interventions aim to reduce distress and teach coping mechanisms, decreasing the likelihood of self-harm. The highest risk occurs when structured support is suddenly removed.
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