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
Explanation
Choice A reason: A rapid weight gain is a common sign of fluid retention, which can indicate an exacerbation of heart failure.
Choice B reason: Being able to breathe easier would typically indicate an improvement in heart failure symptoms, not an exacerbation.
Choice C reason: Cooking dinner suggests a level of activity that is not indicative of an exacerbation of heart failure.
Choice D reason: The absence of swelling in the feet would generally be a positive sign, not indicative of an exacerbation of heart failure.
Correct Answer is D
Explanation
Choice A reason: Cyclothymic disorder involves periods of hypomanic symptoms, but not continuously for 2 years.
Choice B reason: Cyclothymic disorder is not a one-time event; it involves multiple episodes of hypomanic and depressive symptoms.
Choice C reason: While chronic depression can be a part of cyclothymic disorder, it alone does not define it.
Choice D reason: Cyclothymic disorder is characterized by at least 2 years of numerous periods of hypomanic symptoms and depressive symptoms.
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