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 C

Explanation

A. “Decreased startle response to loud noises.”: Individuals with PTSD often have an exaggerated startle response to loud noises or unexpected stimuli. This heightened startle response is a common symptom of hyperarousal associated with PTSD. Therefore, a decreased startle response would be unexpected in this context.

B. “Reports uninterrupted sleep of 10 to 12 hr each night.”: Sleep disturbances are common among individuals with PTSD. Symptoms can include difficulty falling asleep, staying asleep, or experiencing nightmares related to the traumatic event. Therefore, reports of uninterrupted sleep for 10 to 12 hours each night would be unexpected in someone with PTSD.

C. “Reluctance to discuss the event that precipitated the distress.”: Avoidance of trauma-related thoughts, feelings, or reminders is a hallmark symptom of PTSD. Individuals with PTSD often avoid discussing or thinking about the traumatic event to cope with distressing memories or emotions. Therefore, reluctance to discuss the precipitating event is a common manifestation of PTSD.

D. “Reports feelings of acute distress that began 2 weeks ago.”: PTSD symptoms typically develop shortly after experiencing a traumatic event, but the diagnosis of PTSD requires that symptoms persist for at least one month. Acute distress that began two weeks ago may indicate an acute stress reaction rather than PTSD. PTSD involves persistent symptoms beyond the acute phase of the trauma.

A. “I can hear him crying in the middle of the night.” B. "He spends most of his time locked in his room.” C. “He refuses to go to the movies with his friends.” D. “I noticed several cutting marks on both of his arms.”

Correct Answer is D

Explanation

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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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 admitting a client who has posttraumatic stress disorder (PTSD) to a community mental health facility. Which of the following manifestations should the nurse expect when completing the admission assessment?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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