A nurse enters the room of a male patient who exhibits suspicious behavior.

The patient yells, “Stay away from my closet!” What is the most appropriate action for the nurse to take?

Choice A rationale
Actively seeking is a stage of chemical dependency where the individual actively seeks out the substance. In this scenario, the teenager is not just seeking heroin, but is using it to prevent withdrawal symptoms, which suggests a more advanced stage of dependency.
Choice B rationale
Experimentation is the initial stage of chemical dependency where the individual first tries the substance. However, the teenager in this scenario is past the experimentation stage as she is using heroin regularly to prevent withdrawal symptoms.
Choice C rationale
Burnout is a stage of chemical dependency characterized by physical and mental exhaustion due to prolonged substance use. While the teenager may be experiencing burnout, the scenario specifically mentions her use of heroin to prevent withdrawal symptoms, which is more indicative of the preoccupation stage.
Choice D rationale
Preoccupation is a stage of chemical dependency where the individual is consumed by thoughts of the substance and uses it to prevent withdrawal symptoms. The teenager’s belief that she cannot cope without heroin and her use of it to prevent withdrawal symptoms align with this stage.

Choice A rationale
While understanding a patient’s past experiences can provide context for their current emotional state, it may not directly address the immediate risk of suicide. It’s important to focus on the present situation and the patient’s current feelings.
Choice B rationale
If a patient has a specific plan for suicide, it indicates a higher level of risk. By asking about their plan, the nurse can assess the immediacy and severity of the patient’s suicidal intent. This information is crucial for determining the appropriate level of care and intervention.
Choice C rationale
This question could be interpreted as validating or encouraging the patient’s suicidal thoughts. It’s essential to promote safety and positive coping strategies, rather than focusing on the perceived benefits of suicide.
Choice D rationale
While it’s important to understand the feelings driving a patient’s suicidal thoughts, asking why they want to end their life can come across as judgmental. It’s more helpful to ask about their feelings and listen empathetically.