A nurse is caring for a client three 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?
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.
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.
The Correct Answer is A
Choice A reason:
When a client expresses thoughts of wanting to end their life, it is crucial for the nurse to immediately assess the risk of suicide. Asking the client if they have a plan to commit suicide is a direct approach to gauge the immediacy and seriousness of the risk. This information is vital for determining the next steps in care, which may include close supervision, safety precautions, and urgent psychiatric evaluation.
Choice B reason:
While ensuring the client is comfortable is important, allowing the client to rest without further assessment or intervention may not be safe if the client is at immediate risk of self-harm. The priority is to assess and secure the client's safety.
Choice C reason:
It is inappropriate and potentially dangerous to dismiss the client's statement as manipulation. All expressions of suicidal ideation should be taken seriously, and the nurse should provide a supportive response that addresses the client's emotional state and safety concerns.
Choice D reason:
Notifying the client's family can be part of a broader safety plan, but it should not replace immediate assessment and intervention by the healthcare team. Family members may provide support, but they are not a substitute for professional care and suicide risk assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
This statement reflects hypervigilance and a persistent sense of threat, which are symptoms associated with PTSD. Individuals with PTSD may feel constantly on edge as if danger is always imminent, leading to behaviors such as checking rooms repeatedly.
Choice B reason:
While this statement indicates a traumatic experience, it does not directly suggest symptoms of PTSD. PTSD is characterized by specific symptoms such as intrusive thoughts, flashbacks, and avoidance behaviors related to the traumatic event.
Choice C reason:
This statement may be indicative of a distressing combat experience but does not directly align with the symptoms of PTSD. It does not reflect the re-experiencing, avoidance, or arousal symptoms typically seen in PTSD.
Choice D reason:
This statement is a clear example of re-experiencing symptoms, which is a core feature of PTSD. Nightmares about the traumatic event and intrusive, distressing memories are common in individuals with PTSD. The vivid and distressing nature of such dreams can significantly impact an individual's well-being.
Correct Answer is B
Explanation
Choice A: I will join a book club in my neighborhood.
Joining a book club in the neighborhood can be a good step towards socializing and overcoming the fear of open or crowded places. However, the success of this step largely depends on the severity of the client's agoraphobia.
Choice B: I plan to sit on a park bench for a few minutes each day.
This is a good practice as it involves gradual exposure to the outside world, which can help in managing agoraphobia. The client can start with a few minutes and then gradually increase the time spent outside.
Choice C: I should avoid entering elevators and other closed spaces.
Avoidance is not a solution for agoraphobia. In fact, avoiding places or situations out of fear can reinforce the phobia. The goal of treatment is to help the client face these situations rather than avoid them.
Choice D: I can try participating in group therapy every week.
Group therapy can be beneficial as it provides a supportive environment where the client can learn from the experiences of others dealing with the same issues. It can also help the client feel less isolated.
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