A client is brought to a busy emergency department by their spouse due to erratic behavior and expressions of despair.
If the client shrugs their shoulders when asked by the triage registered nurse if they feel suicidal now, what nursing responsibility is the practical nurse expected to be assigned?
Ask the client to make a verbal contract to not harm self.
Return the client to the waiting room with the spouse.
Document that the client is not currently suicidal.
Place the client in an ideal situation with one-on-one observation.
The Correct Answer is D
Choice A rationale
Asking the client to make a verbal contract to not harm themselves is a common strategy used in suicide prevention. However, it is not the primary responsibility of the practical nurse in this scenario.
Choice B rationale
Returning the client to the waiting room with the spouse is not the most appropriate action. The client’s safety is the top priority, and they should be closely monitored due to their erratic behavior and expressions of despair.
Choice C rationale
Documenting that the client is not currently suicidal is important, but it is not the primary responsibility of the practical nurse in this scenario. The client’s non-verbal cues (shrugging their shoulders) suggest they may be at risk.
Choice D rationale
The primary responsibility of the practical nurse in this scenario would be to place the client in an ideal situation with one-on-one observation. This ensures the client’s safety and allows for immediate intervention if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Confusion can cause a temporary state of disorientation and difficulty with concentration and memory, but it doesn’t typically result in a loss of multiple abilities such as short- and long- term memory, language, and the ability to understand.
Choice B rationale
Dementia is a progressive condition that affects memory, thinking skills, and the ability to perform everyday tasks. It can cause loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.
Choice C rationale
Delirium is a sudden and severe confusion that comes on quickly and can cause changes in memory, thinking, attention, and perception. However, it is usually temporary and reversible, unlike the progressive loss of abilities seen in dementia.
Choice D rationale
Aggression is a type of behavior characterized by hostile, forceful, or destructive actions. It does not involve a loss of multiple abilities such as short- and long-term memory, language, and the ability to understand.
Correct Answer is D
Explanation
An 80-year-old patient with chronic obstructive pulmonary disease, chronic respiratory failure, and urosepsis is at the highest risk for developing delirium. Multiple factors such as advanced age, severe illness, and multiple comorbidities increase the risk of delirium.
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