A nurse is caring for a client three days after admission to an acute care mental health facility for treatment of major 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 nursing interventions is appropriate?
Ask the client if she has a plan to commit suicide.
Notify the client's family and request a visitor to stay with the client until thoughts of suicide are gone.
Recognize the attempt at manipulation and escort the client back to her activity.
Assist the client to her room and allow her to rest before resuming activity.
The Correct Answer is A
Choice A reason: Directly asking the client about suicidal plans is a critical step in assessing risk and determining the need for immediate intervention.
Choice B reason: While involving the family is important, it does not address the immediate risk the client may pose to herself.
Choice C reason: Recognizing the statement as a manipulation attempt is inappropriate; all expressions of suicidal ideation should be taken seriously.
Choice D reason: Allowing the client to rest does not address the immediate risk of suicide and the need for urgent assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
Choice A reason: Clang associations, or speech governed by the sound of words rather than their meaning, are common in manic episodes.
Choice B reason: Impulsive behaviors such as spending large sums of money are characteristic of mania.
Choice C reason: Increased sociability and flirtatious behavior can be observed in individuals experiencing mania.
Choice D reason: Sleeping for long periods is not typically associated with manic behavior; rather, reduced need for sleep is more common.
Choice E reason: Rapid, continuous speech is a symptom of manic behavior, often making it difficult for others to interrupt.
Correct Answer is C
Explanation
Choice A reason: This statement is not appropriate as it may sound condescending and does not acknowledge the client's effort in a respectful manner.
Choice B reason: This question could be perceived as intrusive and might make the client feel defensive about their self-care activities.
Choice C reason: This response is appropriate as it is a neutral observation that acknowledges the client's effort without making judgments or assumptions.
Choice D reason: While this statement is positive, it may not be the best choice as it could be interpreted as patronizing rather than a simple acknowledgment.
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