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
Explanation
Rationale:
A. Observing the final 2 minutes is not sufficient for detecting acute transfusion reactions, which can occur at any time during the transfusion.
B. Observing the final 15 minutes is also not adequate; reactions can occur earlier.
C. The first 15 minutes is the most critical time for observing for transfusion reactions, as most reactions occur during this period.
D. The first 2 minutes are too brief to detect potential transfusion reactions, which typically manifest within the first 15 minutes.
Correct Answer is ["B","D","E"]
Explanation
Rationale:
A. The Harvard Implicit Association Test (IAT) measures implicit biases and is not used specifically for assessing suicide risk.
B. The PHQ-9 (Patient Health Questionnaire-9) is a validated tool for screening, diagnosing, monitoring, and measuring the severity of depression, which is closely related to suicide risk.
C. The Altman Self-Rating Mania Scale is used to assess the severity of manic symptoms in clients with bipolar disorder, not for suicide risk assessment.
D. The SAD PERSONS scale is a tool specifically designed to assess suicide risk based on key risk factors.
E. The SAFE-T (Suicide Assessment Five-Step Evaluation and Triage) is a comprehensive framework for assessing suicide risk, making it an appropriate tool to include in suicide risk assessments.
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