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 D
Explanation
Choice A reason: While rest may help alleviate nausea, it is not the first action a nurse should take when a client on digoxin reports nausea, as it could be a sign of toxicity.
Choice B reason: A dietary consult may be beneficial in the long term but is not the immediate priority when a client reports nausea, which could be a symptom of digoxin toxicity.
Choice C reason: Requesting an order for an antiemetic is not the first step without assessing whether the nausea is due to digoxin toxicity, which can be life-threatening.
Choice D reason: Checking the client's vital signs is the correct first action because nausea can be a sign of digoxin toxicity, and vital signs may reveal other symptoms of toxicity.
Correct Answer is B
Explanation
Choice A reason: Weighing monthly is not frequent enough to monitor fluid status effectively in a patient with chronic heart failure.
Choice B reason: Weighing daily is recommended to detect early signs of fluid retention, which is crucial for patients with chronic heart failure.
Choice C reason: Weighing twice a day is not typically necessary unless specifically recommended by a healthcare provider for close monitoring.
Choice D reason: Weighing weekly may miss early signs of fluid retention and is not recommended for daily monitoring of fluid status in chronic heart failure.
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