Susan, the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?
Lethality of the method and availability of means
Client's educational and economic background
Client's insight into the reasons for the decision.
Quality of the client's social support
The Correct Answer is A
A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.
B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.
C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.
D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.
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Related Questions
Correct Answer is C
Explanation
A. "Exposure to sunlight will help to strengthen your eyes.": Sunlight exposure is not recommended as it can exacerbate symptoms.
B. "These are unusual symptoms. I will ask the provider for an ophthalmology referral.": These symptoms are characteristic of Graves' ophthalmopathy and do not require an immediate referral unless severe.
C. "Eye drops and dim lighting can improve your symptoms." These interventions can help alleviate discomfort associated with dryness and light sensitivity in hyperthyroidism-related eye changes (Graves' ophthalmopathy). Dim lighting reduces glare, which can be uncomfortable for clients with sensitivity to light. Eye drops can provide lubrication for dry eyes.
D. "Surgery will be necessary to correct the damage to your eyes.": Surgery is considered for severe cases or when other treatments fail, not typically as an initial intervention.
Correct Answer is A
Explanation
A. Lethality of the method and availability of means. Assessing the method and means helps determine the immediacy and seriousness of the threat. Knowing the lethality of the method and whether the means are readily available informs the level of intervention needed to keep the client safe.
B. Client's educational and economic background: While socioeconomic factors can influence mental health, they are not immediate priorities in a suicidal crisis.
C. Client's insight into the reasons for the decision: Insight is important for understanding motivations but is secondary to immediate safety concerns.
D. Quality of the client's social support: Social support is crucial but is secondary to assessing imminent risk of harm.
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