A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

Refer the client to a support group for survivors of suicide

Offer to contact the client’s family or support system

Inform the client that feelings of guilt are often felt by survivors of suicide

Determine the clients understanding of the suicide events

Answer and Explanation

The Correct Answer is D

A. Refer the client to a support group for survivors of suicide: While support groups can be valuable resources for individuals who have lost loved ones to suicide, it may not be the most immediate or appropriate action to take first. The client may not be ready to engage in group support until her immediate needs are addressed.

B. Offer to contact the client’s family or support system: This option demonstrates empathy and practical support by offering assistance in reaching out to the client's family or support system. It can help ensure that the client has immediate emotional support and assistance with practical matters.

C. Inform the client that feelings of guilt are often felt by survivors of suicide: While providing information about common experiences of survivors of suicide can be helpful, it may not be the most immediate action to take first. The client's emotional needs and immediate concerns should be addressed before discussing broader aspects of grief and guilt.

D. Determine the client's understanding of the suicide events: This option involves assessing the client's understanding of the circumstances surrounding the suicide. Understanding the client's immediate thoughts, feelings, and perceptions of the event is essential for providing appropriate support and intervention.

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Correct Answer is A

Explanation

A. Weight gain and dry mouth: Weight gain and dry mouth are common adverse effects of lithium at therapeutic levels. They are not immediately dangerous but can affect compliance with the medication regimen.

B. Oliguria (reduced urine output) and muscle weakness are more concerning symptoms. They can indicate potential toxicity, especially oliguria, which suggests possible renal impairment, a serious concern with lithium therapy.

C. Hallucinations and blurred vision are more severe and typically associated with lithium toxicity rather than therapeutic levels. They indicate a need for immediate medical attention.

D. Coarse hand tremors and confusion: Coarse hand tremors and confusion are signs of lithium toxicity. At therapeutic levels, fine hand tremors can occur, but coarse tremors and confusion suggest higher serum levels.These symptoms are associated with toxicity and require urgent medical evaluation.

A. Provide additional attention to the client B. Apply mechanical restraints before administering medication C. Obtain a verbal contract from the client D. Limit staff members who work with the client

Correct Answer is C

Explanation

A. Provide additional attention to the client: While individuals with BPD may crave attention and validation, providing excessive attention can reinforce maladaptive behaviors. Instead, the focus should be on providing consistent and appropriate support while also setting boundaries to encourage healthy coping mechanisms.

B. Apply mechanical restraints before administering medication: Mechanical restraints should only be used as a last resort when less restrictive interventions have failed to ensure the safety of the client and others. Applying restraints before attempting other interventions is not appropriate and may escalate the situation.

C. Obtain a verbal contract from the client: A verbal contract is an agreement between the client and the treatment team regarding safety measures and coping strategies. This intervention involves collaboratively establishing agreements with the client, which can help empower them to take responsibility for their behaviors and engage in treatment planning.

D. Limit staff members who work with the client: Limiting staff members who work with the client may inadvertently isolate the client and hinder the development of therapeutic relationships. Consistency in staffing and a collaborative approach among team members are often more beneficial in providing comprehensive care.

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A nurse is caring for a client who has just learned that her partner has died by suicide. Which of the following actions should the nurse take first

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a client who is taking lithium. Which of the following should the nurse include in the teaching as adverse effects of therapeutic lithium level?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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