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.

Answer and Explanation

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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Correct Answer is A

Explanation

A. This statement refers to the "duty to warn," a legal obligation to protect third parties if a client expresses a serious threat of harm to others. It's a crucial exception to confidentiality.
B. This statement is inaccurate as there are scenarios where healthcare workers are legally required to provide information to the court.
C. This statement is not entirely accurate; there are legal boundaries and requirements for disclosing client information to attorneys.
D. Confidentiality extends even after a client's death in many situations, but there are exceptions based on state laws and ethical guidelines.

A. "On a regular basis, do you get enough restful sleep?" B. "Can we discuss what triggered your angry outburst a few minutes ago?" C. "Are you experiencing a flashback of the rape right now?" D. "Am I correct to say that you try to avoid certain family members?"

Correct Answer is C

Explanation

A. Sleep disturbances are common in PTSD but might not address the immediate distress related to the sexual assault.
B. While discussing triggers is relevant, it might not directly address the current acute symptoms of reliving the traumatic event.
C. Asking about current experiences of flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but asking about flashbacks addresses more immediate distress.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?

Correct Answer is A

Explanation

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

Correct Answer is C

Explanation

Which experiences are most likely to precipitate posttraumatic stress disorder (PTSD)? (Select all that apply.)

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

Which statement provides the best rationale for why a nurse should closely monitor a severely depressed patient during antidepressant medication therapy?

A soldier returns to the United States from active duty in a combat zone. The soldier is diagnosed with posttraumatic stress disorder (PTSD). The nurse's highest priority is to screen this soldier for which problem?

A nurse is teaching a newly licensed nurse about appropriate actions to take when a client threatens to harm a specific individual. Which of the following statements by the newly licensed nurse indicates understanding?

A nurse is caring for a client who has depression. The client refuses to get out of bed, go to activities, or participate in any of the unit's programs. Which of the following responses should the nurse make?

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions?