A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?

The client has begun playing basketball with several other clients during the past month.

The client identifies with problems expressed by other clients.

The client's behavior has become impulsive in the past few weeks.

The client states she wants to go home to be with her children and partner.

Answer and Explanation

The Correct Answer is C

A. The client has begun playing basketball with several other clients during the past month.

Engaging in activities and social interactions can actually be a positive sign, as it suggests involvement and connection with others, which can be protective against suicide.

B. The client identifies with problems expressed by other clients.

Identifying with others' problems may indicate empathy, but it is not necessarily indicative of suicide risk on its own.

C. The client's behavior has become impulsive in the past few weeks.

Explanation: Impulsivity can be a significant risk factor for suicide. A sudden increase in impulsive behavior might indicate that the client is not thinking clearly and is acting without considering the potential consequences. Impulsivity can lead to actions that are harmful or dangerous, including suicidal behaviors.

D. The client states she wants to go home to be with her children and partner.

Expressing a desire to be with loved ones is generally not an indicator of suicide risk. In fact, having a strong support system can be protective against suicidal thoughts.

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Correct Answer is D

Explanation

A. An adolescent client who throws objects at other clients:

Explanation: Seclusion is contraindicated for this client due to safety concerns. The behavior of throwing objects at others indicates a potential danger to both the client and others in a confined space. Placing the client in seclusion could escalate the situation and potentially lead to further harm.

B. An older adult client who is manic and crying due to overstimulation:

Explanation: Seclusion might be contraindicated for this client as well. Older adults experiencing manic behavior and emotional distress could be further traumatized by seclusion. Alternatives like providing a calm and soothing environment, along with appropriate medications, might be more beneficial for this client.

C. A school-age client who attempts to repeatedly bite staff:

Explanation: Seclusion is a potential option for this client. The repeated attempts to bite staff pose a risk of physical harm to both the client and staff members. Seclusion might be used as a last resort to ensure the safety of everyone involved.

D. An adult client following a suicide attempt:

Explanation: Seclusion is generally contraindicated for clients who have attempted suicide. Placing them in isolation can worsen feelings of despair and isolation, potentially increasing the risk of self-harm or suicide. These clients require close monitoring, support, and therapeutic interventions to address the underlying issues.

A. Plan the client's schedule to allow time for rituals. B. Confront the client about the senseless nature of the repetitive behaviors. C. isolate the client for a period of time. D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Correct Answer is A

Explanation

A. Plan the client's schedule to allow time for rituals.

Explanation:

For individuals with obsessive-compulsive disorder (OCD), engaging in rituals or repetitive behaviors can be a way to manage anxiety. Allowing time for these rituals within the client's schedule, while gently working towards reducing their impact, is a part of a gradual therapeutic approach known as Exposure and Response Prevention (ERP). ERP aims to help the client gradually face their anxiety triggers while refraining from engaging in compulsions.

Why the other choices are incorrect:

B. Confront the client about the senseless nature of the repetitive behaviors.

Confrontation can increase the client's anxiety and resistance to treatment. Instead, the nurse should approach the client with understanding and gradually work on strategies to reduce the compulsive behaviors.

C. Isolate the client for a period of time.

Isolating the client is not a therapeutic approach for managing OCD. It can lead to increased distress and negatively impact their mental health. Inclusion and support are more effective strategies.

D. Set strict limits on the behaviors so that the client can conform to the unit rules and schedules.

Setting strict limits may escalate the client's anxiety and could be counterproductive. It's important to work collaboratively with the client and apply evidence-based approaches like ERP to manage their symptoms effectively.

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A nurse in an acute care mental health facility is assessing a client who has bipolar disorder. Which of the following findings indicates the client is at risk for suicide?

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Explanation

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