After establishing a no-harm contract with the client, the nurse should:
continue to maintain close observation.
begin treatment with antidepressants.
begin to assess client risk factors.
decrease observation activity to allow client autonomy.
The Correct Answer is A
A. A no-harm contract is a useful tool. However, it's essential to remember that it's not a guarantee against self-harm. Close observation remains crucial, as suicidal ideation can fluctuate.
B. Antidepressants can be part of the treatment plan but they are not an immediate solution and require careful monitoring. The priority is ensuring the client's safety.
C. This assessment should have already been conducted before establishing the no-harm contract. Ongoing assessment is important, but immediate observation takes precedence.
D. Reducing observation could put the client at risk. Continuous monitoring is necessary to prevent self- harm.
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Related Questions
Correct Answer is B
Explanation
A. Preferring to eat meals while watching TV is a common behavior that is not specifically associated with suicidal ideation. It may simply reflect the adolescent's comfort or routine preferences rather than a sign of continued suicidal intent.
B. Giving away personal belongings, such as a CD collection, can be a sign that the adolescent is making arrangements for their belongings in case of death. This behavior can sometimes suggest that the individual may be planning for their end, which could indicate lingering suicidal thoughts. It's important to explore this behavior further with the adolescent to understand their intentions and state of mind.
C. While avoidance of discussing the suicide attempt may indicate emotional distress or a reluctance to engage, it does not directly point to ongoing suicidal intent. It could also reflect a desire for privacy or difficulty in expressing feelings, rather than a clear indication of suicidal ideation.
D. Adolescents often express a desire to spend more time with peers rather than family, which is a common developmental behavior. This preference alone does not necessarily indicate suicidal intent and is more reflective of typical adolescent social behavior.
Correct Answer is B
Explanation
A. It is typically part of a neurological or mental status examination rather than a functional assessment. Functional assessments are more concerned with how well a client can manage daily tasks and their overall ability to live independently.
B. The primary purpose of a functional assessment is to determine the client’s ability to perform activities of daily living (ADLs). ADLs include tasks such as bathing, dressing, grooming, eating, toileting, and mobility. This assessment helps to identify areas where the client may need assistance and guides the development of a care plan to support their independence and quality of life.
C. While assessing cognitive functions such as reasoning, judgment, and thought processes can be part of a comprehensive evaluation, it is not the primary goal of a functional assessment. These cognitive aspects are more relevant in mental status examinations or neuropsychological assessments.
D. Assessing memory is important for understanding cognitive function, but it is not the main focus of a functional assessment. Functional assessments are centered around evaluating practical abilities related to daily living rather than specific cognitive functions like memory.
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