A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

Allow no glass or metal on meal trays.

Check the patient's whereabouts every 15 minutes and make frequent verbal contact.

Remove all potentially harmful objects from the patient's possession.

Maintain arm's length, one-on-one nursing observation around the clock.

Answer and Explanation

Correct Answer : A,B,C

A.   This precaution helps eliminate potential means for self-harm.
B.   Regular checks and verbal contact are essential to monitor the patient's safety and provide support.
C.   Removing objects that could be used for self-harm is a key part of suicide precautions.
D.   While this is an intensive level of observation, it might not be feasible at all times due to staffing limitations, making this choice less practical than the others.

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Correct Answer is C

Explanation

A. Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. The situation requires more immediate assessment and action due to the expressed suicidal ideation.

A. Decreased extrapyramidal symptoms B. Reduced levels of motor activity C. Logical thought processes D. Mood improvement

Correct Answer is D

Explanation

A. Extrapyramidal symptoms are more commonly associated with antipsychotic medications rather than SSRIs.
B. SSRIs might have varying effects on motor activity, but this is not a primary outcome for their use.
C. While SSRIs may indirectly contribute to cognitive improvements, the primary expected outcome revolves around mood changes rather than thought processes.
D. SSRIs are primarily used to treat mood disorders like depression and anxiety, and the main goal of their use is to improve mood and emotional symptoms. Therefore, the expected outcome criteria often relate to mood improvement.

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A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse caring for a patient prescribed a selective serotonin reuptake inhibitor (SSRI) will develop outcome criteria related to what outcome?

Correct Answer is D

Explanation

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