A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life.
Which of the following actions should the nurse take?.
Ask the client about the lethality of their plan
Encourage the client to focus on the positive aspects of life.
Reassure the client that everything is going to work out.
Allow the client time alone to self-reflect.
The Correct Answer is A
Choice A rationale:
Asking the client about the lethality of their plan is the most appropriate action. This allows the nurse to assess the immediate risk to the client’s safety.
Choice B rationale:
Encouraging the client to focus on the positive aspects of life may be helpful in some situations, but it does not address the immediate safety concern.
Choice C rationale:
Reassuring the client that everything is going to work out may provide temporary relief, but it does not address the immediate safety concern.
Choice D rationale:
Allowing the client time alone to self-reflect is not appropriate in this situation as it could increase the risk of self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Opiate withdrawal is a condition that occurs when a person stops using opiates after prolonged use. It is characterized by symptoms such as restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes. The AIMS assessment is not typically used for this condition.
Choice B rationale:
Tardive dyskinesia is a movement disorder characterized by irregular, involuntary movements most commonly in areas of the face, around the eyes, and of the mouth, including the jaw, tongue, and lips. The AIMS assessment is a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of abnormal movements of the face, limbs, and body in patients with tardive dyskinesia.
Choice C rationale:
Alcohol withdrawal is a condition that can occur when a person who has been drinking too much alcohol every day suddenly stops drinking alcohol. Symptoms can include tremors, anxiety, nausea and vomiting, headaches, increased heart rate, and seizures. The AIMS assessment is not typically used for this condition.
Choice D rationale:
Lithium toxicity, also known as lithium overdose, can occur if you take too much lithium, a mood-stabilizing medication. Symptoms can include hand tremor, increased thirst, increased urination, diarrhea, vomiting, weight gain, and impaired memory. The AIMS assessment is not typically used for this condition.
Correct Answer is C
Explanation
Choice A rationale:
Schizophrenia is typically not diagnosed in school-age children. Symptoms may begin to appear in late adolescence, but diagnosis usually occurs in adulthood.
Choice B rationale:
Schizophrenia is not typically diagnosed in preschoolers. Symptoms of schizophrenia are rarely seen in children this young.
Choice C rationale:
Schizophrenia is most commonly diagnosed in young adulthood. This is when symptoms such as hallucinations, delusions, and disorganized thinking typically become apparent.
Choice D rationale:
While schizophrenia can be diagnosed in older adulthood, it is less common. Most individuals with schizophrenia are diagnosed earlier in life.
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