A nurse is caring for a client who is experiencing suicidal thoughts.
Which of the following actions should the nurse take?.
Place the client on 12-hour observation.
Remove harmful objects from the client's room.
Encourage visitors for the client at any time.
Encourage visitors to bring items to the client.
The Correct Answer is B
Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
Correct Answer is D
Explanation
Choice A rationale:
While acknowledging the voices can be part of therapeutic communication, it’s not the first response a nurse should make.
Choice B rationale:
Telling the client that the voices are part of their illness can be helpful, but it’s not the first response a nurse should make.
Choice C rationale:
Asking about the frequency of the voices can be part of the assessment, but it’s not the first response a nurse should make.
Choice D rationale:
Asking what the voices are saying can help assess if the client is experiencing command hallucinations, which could pose a safety risk.
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