A nurse is caring for a client who has just learned that their 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 client's understanding of the suicide events.

Answer and Explanation

The Correct Answer is D

A reason: Refer the client to a support group for survivors of suicide. While referring the client to a support group is important for long-term support, it is not the immediate priority in this acute moment of grief.

B reason: Offer to contact the client's family or support system. Offering to contact family or support systems is supportive but not the first priority. The nurse should first assess the client's immediate emotional and cognitive state.

C reason: Inform the client that feelings of guilt are often felt by survivors of suicide. Providing information about common feelings of guilt can be helpful, but the nurse should first understand the client's current state and their specific needs.

D reason: Determine the client's understanding of the suicide events. The first priority is to assess the client's understanding and emotional response to the news. This helps the nurse provide appropriate support and address any immediate misconceptions or distress.

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Correct Answer is A

Explanation

A reason: Dissociation. Dissociation involves a disconnection between thoughts, identity, consciousness, and memory. The inability to recall details of a traumatic event is a common dissociative response in PTSD, where the mind separates from the distressing experience.

B reason: Rationalization. Rationalization involves creating a logical explanation to justify unacceptable feelings or behaviors. It does not involve memory loss or detachment from the event, making it an incorrect choice in this context.

C reason: Undoing. Undoing is a defense mechanism where a person tries to reverse or undo feelings by doing something that indicates the opposite feeling. It does not involve forgetting or dissociating from traumatic events.

D reason: Reaction formation. Reaction formation involves expressing the opposite behavior or emotion of what one truly feels. It does not involve memory loss or dissociation from the traumatic event, making it an incorrect choice in this context.

A. Delusion. B. Hallucination. C. Attention-seeking behavior. D. Self-mutilation.

Correct Answer is D

Explanation

A reason: Delusion. A delusion is a false belief held despite clear evidence to the contrary. While the client's statement might reflect a distorted perception of reality, the expression of wanting to use a pen to "cut the pain out" indicates a more immediate risk of self-harm.

B reason: Hallucination. Hallucinations involve perceiving something that is not present, such as hearing voices or seeing things that are not there. The client's statement does not indicate a hallucination, but rather a desire to engage in self-harm.

C reason: Attention-seeking behavior. While attention-seeking behavior might be a consideration, the specific request to use a pen to harm themselves suggests a more severe risk of self-mutilation rather than merely seeking attention.

D reason: Self-mutilation. The client's statement clearly indicates a risk for self-mutilation. Expressing the intention to use a pen to harm themselves requires immediate intervention to ensure their safety.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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