A nurse in the Emergency Department is caring for a client with symptoms of depression and admits to thoughts of self-harm with a plan. The client has a history of borderline personality disorder, depression, and substance abuse. Which of the following is the priority action by the nurse?
Reviewing the client's toxicology laboratory report.
Initiating suicide precautions.
Making a contract with the client for eating behavior.
Administering the Hamilton Depression Scale.
The Correct Answer is B
Choice A rationale:
Reviewing the client's toxicology laboratory report is not the priority action in this situation. While assessing toxicology can provide valuable information, the immediate concern is the client's safety due to their admission of thoughts of self-harm with a plan. Toxicology can be relevant but addressing the immediate risk takes precedence.
Choice B rationale:
Initiating suicide precautions is the priority action in this case. The client's admission of thoughts of self-harm with a plan indicates a high risk for suicide. Suicide precautions involve closely monitoring the client, removing any potential means of self-harm, and providing a safe environment. Addressing the client's immediate safety is of utmost importance.
Choice C rationale:
Making a contract with the client for eating behavior is not the priority action in this situation. While eating behavior might be a concern for some individuals with borderline personality disorder, depression, and substance abuse, the client's current statement about self-harm takes precedence. Ensuring the client's safety comes before addressing other aspects of their care.
Choice D rationale:
Administering the Hamilton Depression Scale is not the priority action in this scenario. While assessing the severity of the client's depression is important, the immediate concern is their safety due to the expressed thoughts of self-harm. Once the client's safety is ensured, further assessment and evaluation can take place.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. Ask the client direct questions about the hallucination.
Choice A rationale:
Asking direct questions about the hallucination helps the nurse understand the client’s experience and assess the content and intensity of the hallucinations. This approach also allows the nurse to provide appropriate support and interventions.
Choice B rationale:
Acting as if the hallucination is real can reinforce the client’s distorted perception of reality, which is not therapeutic. The nurse should acknowledge the client’s experience without validating the hallucination as real.
Choice C rationale:
Telling the client to go to their room and that the hallucinations should go away is dismissive and does not address the client’s immediate needs. It is important to engage with the client and provide support rather than dismiss their experience.
Choice D rationale:
Instructing the client to argue with the voices can increase the client’s distress and is not a recommended therapeutic approach. Instead, the nurse should help the client find ways to cope with and manage the hallucinations.
Correct Answer is ["A","B","E"]
Explanation
Answer and explanation
The correct answers are choices A. Depression, B. Obsessive-compulsive disorder, E. Anxiety.
Choice A rationale:
Depression commonly coexists with eating disorders. The individual's distorted body image, feelings of low self-worth, and dietary restrictions can contribute to the development of depressive symptoms.
Choice B rationale:
Obsessive-compulsive disorder (OCD) often occurs alongside eating disorders. The obsessions and compulsions seen in OCD can overlap with behaviors related to food, eating rituals, and body image, reinforcing the eating disorder pathology.
Choice C rationale:
Schizophrenia is not typically considered a comorbidity of eating disorders. Schizophrenia involves disruptions in thought processes, emotions, and perceptions, which are distinct from the cognitive distortions and behaviors associated with eating disorders.
Choice D rationale:
Breathing-related sleep disorder is not a commonly recognized comorbidity of eating disorders. While sleep disturbances might occur in individuals with eating disorders due to physical discomfort or anxiety, a specific link to breathing-related sleep disorder is less established.
Choice E rationale:
Anxiety is a well-recognized comorbidity of eating disorders. Anxiety often accompanies the intense fears, worries, and preoccupations related to body weight, shape, and eating behaviors that are characteristic of eating disorders.
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