A nurse is assigned to care for several clients on a mental health unit. One of the clients who has suicidal ideation starts to verbalize clear intent to self harm. Which of the following actions should the nurse take?

Request the client’s caregivers to remain with the client.

Notify the supervisor that the client requires one to one nursing observation

Assign the client to, a private room.

Increase the frequency of client assessment to hourly.

Answer and Explanation

The Correct Answer is B

A) "Request the client’s caregivers to remain with the client.": While having caregivers present can provide some emotional support, this is not a sufficient or appropriate intervention when a client is actively expressing intent to self-harm. Caregivers may not be trained to recognize subtle changes in the client’s condition, and they might not be able to provide the level of safety required. It is essential that a trained nurse or professional provides direct observation.

B) "Notify the supervisor that the client requires one-to-one nursing observation.": This is the most appropriate and immediate action when a client verbalizes a clear intent to self-harm. One-to-one nursing observation ensures that the client is under constant surveillance, which is crucial for preventing harm and providing immediate intervention if the client attempts to act on their suicidal thoughts.

C) "Assign the client to a private room.": Assigning the client to a private room is not a recommended action when the client is expressing intent to self-harm. In fact, isolation in a private room could increase the risk of harm. The priority is to ensure the client is closely monitored, and being placed in a private room may reduce the ability for staff to observe and intervene as needed.

D) "Increase the frequency of client assessment to hourly.": While increasing the frequency of assessments is important, it is not sufficient to prevent self-harm in a client who is at immediate risk. The client needs continuous observation to ensure their safety. One-to-one nursing observation is more effective than periodic assessments for clients with active suicidal ideation or intent.

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Correct Answer is D

Explanation

A) I participate in physical activities 3 times per week: Engaging in physical activity is a positive behavior and is not considered high-risk. Regular physical activity is important for maintaining overall health and preventing obesity, cardiovascular disease, and other health issues.

B) I use sunscreen with an SPF of 10: While using sunscreen is a protective behavior, an SPF of 10 is lower than the recommended SPF of at least 30 for effective protection against harmful UV radiation. This is not the most significant high-risk behavior compared to others, but it still indicates some risk of sun damage.

C) I limit playing video games to 3 hours per day: Limiting screen time to 3 hours per day can be considered a balanced approach to video gaming. While excessive screen time can be problematic, 3 hours per day is not necessarily a high-risk behavior for an adolescent, as long as it doesn't interfere with other important aspects of life, like physical activity, sleep, and socialization.

D) I have had sexual relations, but did not get the HPV vaccine: Engaging in sexual activity without receiving the HPV vaccine is a high-risk behavior. The HPV vaccine helps prevent certain strains of the human papillomavirus, which can cause cervical cancer and other cancers. Lack of vaccination increases the risk of contracting HPV and developing related complications.

A. Turn on overhead lights briefly when checking IV line B. Open curtains between clients semiprivate rooms C. Conduct change-of-shift report near the clients’ rooms. D. Wear shoes with rubber soles

Correct Answer is D

Explanation

A) "Turn on overhead lights briefly when checking IV line.": Turning on overhead lights can disrupt the client’s sleep, especially if done during the night. Light exposure can interfere with the body’s natural circadian rhythm, making it harder for the client to fall asleep and stay asleep. A more appropriate action would be to use a dim light or portable light to minimize disturbance.

B) "Open curtains between clients’ semiprivate rooms.": Opening the curtains between semiprivate rooms could increase noise and visual distractions, which may disturb the client's sleep. Keeping the environment as calm and private as possible is essential to reduce stress and promote restful sleep. Curtains should ideally remain closed to promote privacy and minimize distractions.

C) "Conduct change-of-shift report near the clients’ rooms.": Conducting report near the client's rooms can create unnecessary noise and disturb the client’s sleep. The change-of-shift report should ideally take place in a designated area, away from patient rooms, to reduce noise and disturbances in the environment.

D) "Wear shoes with rubber soles.": Wearing shoes with rubber soles reduces noise when walking, which is particularly important in an acute care setting where patients need rest. Quiet movement helps to maintain a peaceful environment, reducing the environmental stressors that can impact sleep quality for clients.

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A nurse is assigned to care for several clients on a mental health unit. One of the clients who has suicidal ideation starts to verbalize clear intent to self harm. Which of the following actions should the nurse take?

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