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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Availability of means and lethality of method is a priority as it directly influences the risk and immediacy of a potential suicide attempt. Access to lethal methods increases the risk of a fatal outcome.
B. The patient's insight into the suicidal motivation is valuable, but it may not indicate immediate risk or specific details about the plan.
C. Quality and availability of social support are important for long-term prevention but may not provide immediate information about the plan or risk.
D. Patient's financial and educational status might be factors contributing to stress but may not directly reflect the immediate risk of suicide.
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.
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