A severely depressed patient who has been on suicide precautions tells the nurse, "I am feeling a lot better, so you can stop watching me. I have taken too much of your time already." Which is the nurse's best response?
"I am glad you are feeling better. The team will consider your request."
"Because we are concerned about your safety, we will continue with our plan."
"I wonder what this sudden change is all about. Please tell me more."
"You should not try to direct your care. Leave that to the treatment team."
The Correct Answer is B
A. While acknowledging the patient's feelings is important, ensuring safety is the priority, and the response should emphasize the ongoing concern for safety.
B. Prioritizing patient safety and care is crucial, especially in situations involving suicidal risks.
C. Encouraging the patient to elaborate further is essential; however, the priority is to maintain the safety precautions.
D. Directing the patient to not participate in their care isn't supportive or therapeutic, especially when safety is a concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Demonstrating empathy would involve acknowledging the client's feelings or beliefs, but the nurse does not validate the client's delusion or express understanding of the client's emotional state. Instead, the nurse redirects the client to the reality of the situation, which is the group therapy session.
B: The nurse's response is therapeutic because it clearly communicates the expectations of the therapy environment. By stating "it is time for group therapy and we expect everyone to attend," the nurse is providing clear, structured guidance without engaging with the delusion, which can help the client understand the reality of the situation and what is required of them.
C: Setting limits on manipulative behavior would involve addressing and curtailing attempts by the client to control or influence a situation for their own benefit. In this scenario, the client's behavior is delusional rather than manipulative, and the nurse's response does not directly set limits on manipulation but rather on adhering to the therapy schedule.
D: Using reflection would mean the nurse is mirroring the client's thoughts or feelings to help them self-reflect. However, the nurse does not reflect the client's statement but instead focuses on the expectations of the therapy program. The nurse's response does not encourage the client to reflect on their own thoughts or feelings but redirects them to the activity at hand.
Correct Answer is C
Explanation
A. While assessing the impact of a suicide attempt on others is important, the immediate focus following a successful suicide attempt in a mental health unit is to ensure the safety of all clients.
B. Restricting group therapy for 72 hours might impede the therapeutic process and does not directly address the safety of clients after a suicide attempt.
C. Following a suicide attempt, it's standard practice to heighten monitoring and implement suicide precautions for all clients to ensure their safety.
D. While assessing the situation is important, immediate intervention to prevent further harm to other clients is a priority following a suicide attempt. The psychological assessment might occur but would not be the primary intervention in this immediate crisis situation.
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