A young-adult client is admitted to the psychiatric unit because of a recent suicide attempt. The client's spouse filled for divorce six months ago, the client lost a job three months ago, and the best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?

Allow the client time alone to sort out any feelings.

Avoid discussing subjects that upset the client.

Encourage activities that allow the client to exert control over the client's environment.

Encourage the client to interact with persons who are recovering from depression.

Answer and Explanation

The Correct Answer is C

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder. Clients with this diagnosis often have intense emotions and may feel vulnerable, so approaching the situation without judgment fosters a sense of safety and respect. This supportive attitude can help build trust and encourage open communication.

B) While providing thorough explanations when cleansing the wound can be beneficial, excessive detail may overwhelm the client or create anxiety. It is important to communicate effectively, but the focus should be on providing care in a compassionate manner rather than on the specifics of the procedure, especially given the client’s emotional state.

C) Asking the client in a non-threatening manner why they cut their abdomen could be perceived as intrusive or confrontational, potentially leading to defensiveness or escalation of emotions. This approach may not be appropriate during a dressing change; instead, it may be more effective to address the reasons for self-harm in a separate therapeutic context when the client is more stable.

D) Requesting another staff member to assist with the dressing change might be necessary in certain situations, but it could also convey a sense of fear or discomfort regarding the client’s behavior. In this case, it is essential for the nurse to manage the situation confidently and compassionately, rather than distancing themselves from the client’s needs. Fostering a supportive environment is more important than involving additional staff at this moment.

A. Explain that these beliefs are related to her illness. B. Explain that distrust is related to feeling anxious. C. Initiate short, frequent contacts with the client. D. Offer to keep the belongings at the nurse's desk.

Correct Answer is C

Explanation

(A) Explain that these beliefs are related to her illness:While it is important to educate the client about their illness, directly challenging their delusions may increase distrust and anxiety. This approach might make the client feel misunderstood and less likely to trust the nurse.

(B) Explain that distrust is related to feeling anxious:This explanation might not be well-received by the client and could be perceived as dismissive of their concerns. It may not effectively address the client’s immediate need for trust and reassurance.

(C) Initiate short, frequent contacts with the client:This approach helps build trust through consistent and reliable interactions. It allows the nurse to establish a rapport without overwhelming the client, thereby promoting a sense of safety and trust. Regular, brief interactions can help the client feel more comfortable and secure.

(D) Offer to keep the belongings at the nurse’s desk:This action might be perceived as an attempt to take control of the client’s belongings, which could reinforce their delusions and decrease trust. It is important to respect the client’s need to keep their belongings close to them.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

Correct Answer is A

Explanation

The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

Correct Answer is C

Explanation

A client with schizophrenia receives a prescription for fluphenazine. Which instruction is most important for the nurse to include when teaching the client about this drug?

A client is admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt. Which nursing problem has the highest priority?

The mental health team working with a homeless client with chronic schizophrenia establishes the treatment goal of, "Improvement in avolition prior to discharge." Which behavior demonstrates achievement of this goal to the nurse?

During admission to the psychiatric unit, a female client is extremely anxious and expresses that she is worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

An older adult woman who lives in a long-term mental health facility has a history of taking belongings from other clients' rooms when she becomes agitated. The client is found placing these items in the same closet on the unit. Which action should the nurse take?