A male client, assessed in the emergency department (ED), has a strong odor of alcohol on his breath. The client denies thoughts of harm to self or others, and the healthcare provider discharges the client. As the client begins to leave, the nurse overhears the client mumble, “Now I’m going to shoot myself.” Which intervention should the nurse implement?
Inquire about the client’s support system.
Ask the client to repeat his comment.
Stop the client from leaving the ED.
Record the statement in the client’s chart.
The Correct Answer is C
A. Inquiring about the client’s support system may be important, but the immediate concern is the statement indicating a potential risk of harm.
B. Asking the client to repeat the comment may not be as effective as taking immediate action to prevent harm.
C. Stopping the client from leaving the ED is the priority to ensure the client's safety and prevent the potential act of self-harm.
D. Recording the statement in the client's chart is important but should be done after taking immediate action to address the potential risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Using relaxation techniques is a positive and appropriate strategy for managing anxiety.
B. Avoiding alcohol and other sedatives is essential as they can potentiate the sedative effects of lorazepam.
C. Moving slowly from a sitting to a standing position is important to minimize orthostatic hypotension, a potential side effect of lorazepam.
D. Stopping the medication if the intended effect is not immediate is not appropriate guidance.
Lorazepam, like many benzodiazepines, may take some time to achieve its full therapeutic effect. Abrupt discontinuation can lead to withdrawal symptoms and should be done under the guidance of a healthcare provider.
Correct Answer is C
Explanation
A. Encouraging daily weigh-ins may exacerbate anxiety and fixation on weight, which is not therapeutic.
B. Exercise and recreation recommendations should align with the treatment plan and be individualized; morning activities are not universally indicated.
C. Allowing the client to select an arts and crafts activity provides a positive outlet for expression and engagement in non-food-related activities.
D. Putting the client in charge of choosing snacks for the unit may not be appropriate, as it could contribute to unhealthy food-related behaviors.
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