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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Tell the client that there is nothing there. Dismissing the client's perception may increase distress and reduce trust in the nurse-client relationship. A therapeutic approach acknowledges the client’s experience without reinforcing or denying hallucinations.
B. Ask the client to describe what is being seen. Encouraging the client to describe the hallucination helps assess its nature and severity. Understanding the content allows the nurse to provide appropriate support, ensure safety, and guide interventions.
C. Touch the client's arm reassuringly. Touching the client without consent, especially during a distressing hallucination, may escalate fear or agitation. Maintaining a calm and non-threatening presence is more appropriate.
D. Remove the client from the room. Relocating the client without assessing the hallucination may not address the underlying distress. Identifying triggers and using therapeutic communication are more effective initial interventions.
Correct Answer is D
Explanation
A. To keep the client's environment calm and with minimal daily stimuli: While a calm environment can help manage acute psychotic symptoms, it is a short-term intervention rather than a long-term goal. Long-term management focuses on adherence to treatment and relapse prevention.
B. To be reoriented to their current environment as needed: Reorientation is beneficial for clients experiencing disorientation due to acute psychosis, but it is a short-term intervention. A long-term goal should focus on maintaining stability and preventing future relapse.
C. To ensure the client participates in a walk with staff on a daily basis: Regular physical activity can improve mental health, but it does not directly address medication adherence or long-term relapse prevention. The goal should focus on strategies to maintain treatment compliance.
D. To develop and acknowledge understanding of a relapse plan prior to discharge: A relapse plan helps the client recognize early warning signs, understand medication importance, and seek support when needed, which is essential for long-term symptom management and prevention of future hospitalizations.
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