A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?
Reassure the client that everything is going to work out.
Ask the client about the lethality of their plan.
Allow the client time alone to self-reflect
Encourage the client to focus on the positive aspects of life.
The Correct Answer is B
Rationale:
A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.
B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.
C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.
D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
Choice A rationale:
Evaluating the infant’s pain level using the FACES Scale is not appropriate for infants. The FACES Scale is typically used for children aged 3 years and older.
Choice B rationale:
Offering the infant small, frequent feedings of thickened liquids is not recommended in this scenario. The infant is on NPO (nothing by mouth) status due to the forceful vomiting and risk of aspiration.
Choice C rationale:
Measuring the infant’s head circumference is important to assess for any signs of increased intracranial pressure or hydrocephalus, which can be associated with vomiting.
Choice D rationale:
Implementing contact precautions is not necessary unless there is a known or suspected infectious cause for the vomiting.
Choice E rationale:
Weighing the infant is crucial to monitor for any significant weight loss, which can indicate dehydration or other underlying issues.
Choice F rationale:
Planning to administer a plain water enema to the infant is not appropriate in this scenario. The primary concern is the forceful vomiting, and an enema would not address this issue.
Correct Answer is A
Explanation
Rationale:
A. Offering information about a support group is a supportive measure that can help the client manage their condition while parenting.
B. Encouraging children to visit the psychiatric unit may not be appropriate or therapeutic for the client or the children.
C. Suggesting that the children live with other relatives is a significant intervention that may not be necessary without further assessment.
D. Notifying child protective services is not warranted unless there is clear evidence of child neglect or abuse.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.