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 B
Explanation
A. Clinical algorithms help in standardizing certain processes but might not specifically integrate evidence-based practice guidelines for evaluating therapy plans.
B. Clinical practice guidelines offer evidence-based recommendations, aiding healthcare providers in decision-making for specific conditions or treatments.
C. While the internet may provide information, it might lack the vetting and credibility of evidence-based practice guidelines provided by reputable sources.
D. Clinical pathways provide a structured approach to care delivery but might not inherently integrate evidence-based practice guidelines unless these are explicitly incorporated into the pathway.
Correct Answer is D
Explanation
A. Extrapyramidal symptoms are more commonly associated with antipsychotic medications rather than SSRIs.
B. SSRIs might have varying effects on motor activity, but this is not a primary outcome for their use.
C. While SSRIs may indirectly contribute to cognitive improvements, the primary expected outcome revolves around mood changes rather than thought processes.
D. SSRIs are primarily used to treat mood disorders like depression and anxiety, and the main goal of their use is to improve mood and emotional symptoms. Therefore, the expected outcome criteria often relate to mood improvement.
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