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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. This response may convey a sense of judgment or imply the client's previous state was unacceptable, potentially making the client feel criticized.
B. This question might inadvertently put the client on the defensive and seems intrusive, possibly making the client uncomfortable.
C. This response is observational and nonjudgmental, acknowledging the change without implying any criticism.
D. This response assumes the reason for the change without allowing the client to express herself and might not accurately reflect the client's emotional state or motivation.
Correct Answer is A
Explanation
A. This statement demonstrates the nurse's willingness to spend time with the patient to build rapport and trust, offering the nurse's presence and support.
B. This statement expresses hope but doesn't directly offer the nurse's presence or support.
C. This question encourages exploration of the patient's feelings but doesn't directly offer the nurse's presence.
D. This statement shares personal experiences but doesn't directly offer the nurse's presence or support.
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