A nurse is providing care to a client who is displaying warning signs of suicidal ideation. Which interventions should the nurse prioritize to ensure the client's safety? (Select all that apply.).
Monitoring the client's access to lethal means.
Encouraging the client to isolate themselves for self-reflection.
Providing the client with a detailed plan for coping.
Collaborating with the client's family and friends.
Administering sedative medications to keep the client calm.
Correct Answer : A,C,D
The correct answer is A. Monitoring the client’s access to lethal means, C. Providing the client with a detailed plan for coping, and D. Collaborating with the client’s family and friends.
Choice A rationale:
Monitoring the client’s access to lethal means is crucial to prevent any immediate risk of self-harm. This includes removing or securing items that could be used for suicide, such as medications, sharp objects, or firearms.
Choice B rationale:
Encouraging the client to isolate themselves for self-reflection is not advisable. Isolation can increase feelings of loneliness and hopelessness, which may exacerbate suicidal ideation.
Choice C rationale:
Providing the client with a detailed plan for coping helps them manage their thoughts and emotions more effectively. This plan can include strategies for dealing with stress, identifying triggers, and knowing when and how to seek help.
Choice D rationale:
Collaborating with the client’s family and friends is essential for creating a support network. Involving loved ones can provide the client with emotional support and help monitor their well-being.
Choice E rationale:
Administering sedative medications to keep the client calm is not a primary intervention for suicidal ideation. While medication may be part of a broader treatment plan, it should not be the sole strategy for ensuring safety.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Collaborate with the patient and the healthcare team.
Choice A rationale:
Prioritize long-term goals over short-term outcomes. This choice is not the most appropriate principle to consider in the planning phase for a patient with suicidal ideation. While setting long-term goals is important, immediate safety and addressing the patient's emotional state take precedence in this situation.
Choice B rationale:
Develop a rigid and unchangeable plan of care. This choice is not suitable for a patient with suicidal ideation. Flexibility in the plan of care is essential to accommodate the patient's changing emotional state and needs. A rigid plan might not effectively address the dynamic nature of suicidal ideation.
Choice C rationale:
Focus only on the patient's physical health. This choice is not comprehensive enough for a patient with suicidal ideation. While physical health is important, addressing the patient's emotional well-being, safety, and mental health concerns should be a priority in the plan of care.
Choice D rationale:
Collaborate with the patient and the healthcare team. This choice is the most appropriate principle to consider. Collaboration involves actively involving the patient in the care planning process and working with the healthcare team to develop a holistic plan that addresses the patient's emotional, psychological, and safety needs. Inclusion of the patient's perspective enhances engagement and increases the likelihood of successful interventions.
Correct Answer is ["B","D"]
Explanation
The correct answer is B. Reflecting back the patient’s feelings and thoughts and D. Encouraging patient involvement in decision making.
Choice A rationale:
Asking close-ended questions is not effective in building rapport and trust. Close-ended questions can limit the patient’s ability to express their feelings and thoughts, which is crucial in understanding their mental state and providing appropriate support.
Choice B rationale:
Reflecting back the patient’s feelings and thoughts helps in validating their emotions and shows that the nurse is actively listening and empathetic. This technique fosters trust and encourages the patient to open up more about their feelings.
Choice C rationale:
Imposing personal views and opinions can be detrimental to the therapeutic relationship. It can make the patient feel judged or misunderstood, which can hinder open communication and trust.
Choice D rationale:
Encouraging patient involvement in decision making empowers the patient and promotes a sense of control over their situation. This collaborative approach can enhance the therapeutic relationship and support the patient’s autonomy.
Choice E rationale:
Disregarding patient preferences is counterproductive in establishing a therapeutic relationship. It can lead to feelings of disrespect and neglect, which can further isolate the patient and exacerbate their risk.
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