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.
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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Related Questions
Correct Answer is B
Explanation
A) Beneficence:
Beneficence refers to the ethical principle of doing good and acting in the best interest of the client. While providing accurate information about the adverse effects of medications contributes to beneficence by ensuring the client’s safety, the specific focus here is on truthfulness in communication, which is more closely aligned with veracity.
B) Veracity:
Veracity is the ethical principle of truthfulness. In this scenario, the nurse is providing honest and accurate information about the medications, including their potential adverse effects. This aligns directly with the principle of veracity, which emphasizes the importance of being truthful and transparent in communication with clients, especially regarding their care and treatment.
C) Justice:
Justice refers to the ethical principle of fairness, ensuring that clients are treated equitably and that their rights are upheld. While the nurse may be demonstrating fairness in the care process, the focus in this scenario is on the truthfulness of the information provided, which is better aligned with the concept of veracity.
D) Autonomy:
Autonomy refers to respecting the client's right to make their own decisions regarding their care. While providing truthful information about medications supports the client’s ability to make informed decisions, the primary ethical principle being demonstrated by the nurse in this scenario is veracity, as the nurse is specifically focused on being truthful with the client.
Correct Answer is B
Explanation
A) Increase in concentration: Chlorpromazine is an antipsychotic medication used to manage symptoms of schizophrenia and other psychotic disorders. While it may have some effects on cognition, an increase in concentration is not the primary therapeutic effect of chlorpromazine.
B) Decrease in delusions: Chlorpromazine is effective in reducing symptoms of psychosis, such as delusions and hallucinations, which are common in conditions like schizophrenia. A decrease in delusions is a direct indicator that the medication is having its intended therapeutic effect.
C) Increase in alertness: Chlorpromazine can cause sedation and drowsiness as side effects, particularly during the initial stages of treatment. An increase in alertness would not be a typical therapeutic outcome, and it may even suggest a side effect like overstimulation or anxiety rather than the intended effect.
D) Decrease in anxiety: While chlorpromazine may have some calming effects, it is primarily used to treat symptoms of psychosis, not anxiety disorders. A decrease in anxiety is not the main therapeutic effect of chlorpromazine. Other medications, such as benzodiazepines, are typically used for anxiety management.
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