A nurse is caring for a client 3 days after admission for treatment of depression. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following actions should the nurse take?
Recognize the attempt at manipulation and escort the client back to her activity.
Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
Ask the client if she has a plan to commit suicide.
Assist the client to her room and allow her to rest before resuming activity.
The Correct Answer is C
A. Dismissing the client's statement as manipulation without proper assessment can be dangerous.
B. While involving family support is important, this response doesn’t address the immediate safety concerns of the client.
C. Asking about suicidal plans helps assess the level of risk and informs subsequent actions to ensure the client's safety.
D. The situation requires more immediate assessment and action due to the expressed suicidal ideation.
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Related Questions
Correct Answer is C
Explanation
A. While assessing the impact of a suicide attempt on others is important, the immediate focus following a successful suicide attempt in a mental health unit is to ensure the safety of all clients.
B. Restricting group therapy for 72 hours might impede the therapeutic process and does not directly address the safety of clients after a suicide attempt.
C. Following a suicide attempt, it's standard practice to heighten monitoring and implement suicide precautions for all clients to ensure their safety.
D. While assessing the situation is important, immediate intervention to prevent further harm to other clients is a priority following a suicide attempt. The psychological assessment might occur but would not be the primary intervention in this immediate crisis situation.
Correct Answer is C
Explanation
Rationale for A: Inviting a family member to be present may hinder communication, especially if the family member is involved in the abuse or the client feels unsafe speaking in their presence. Privacy is crucial for encouraging open communication.
Rationale for B: Providing basic wound care is important for physical injuries, but it does not directly address promoting communication. The nurse should focus on creating a safe environment for the client to talk.
Rationale for C: Being direct and honest when speaking with the client promotes trust and open communication. Clients who are suspected of being abused may be fearful or reluctant to share information, so clear, respectful communication helps create a supportive environment.
Rationale for D: Probing the client for a factual account of the abuse may make the client feel pressured or overwhelmed. The nurse should allow the client to share information at their own pace without feeling forced to disclose details.
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