A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?
"Since you are trying to follow the treatment plan, we can submit your request to the provider."
"We are concerned about you and need to keep you safe."
"If you complete a contract that states you will not harm yourself, you can be alone."
"Until your medication has reached therapeutic levels, you will need constant observation."
The Correct Answer is B
Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.
Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.
Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.
Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Cautioning the client against feeling angry at the deceased sibling could invalidate the client's natural grieving process. Anger is a common and expected emotion in the stages of grief, and acknowledging it can be therapeutic. It is important for the nurse to provide a safe space for the client to express all emotions related to their loss.
Choice B reason: Recommending more solitary activities might not be beneficial for a client experiencing depression after a significant loss. Social support and engagement in social activities can be crucial for recovery. Isolation can exacerbate feelings of loneliness and depression. Instead, the nurse should encourage the client to maintain connections with supportive friends and family members.
Choice C reason: Explaining that the duration of grief is highly variable and can last for years is important. Grief does not have a set timeline, and individuals experience it differently. Providing this information can help normalize the client's feelings and reassure them that what they are experiencing is a part of the healing process.
Choice D reason: Encouraging the client to avoid discussing the events surrounding the sibling's death can hinder the grieving process. Open communication about the loss and the associated emotions is essential for healing. The nurse should encourage the client to share their feelings and memories when they feel ready, as this can be a part of the therapeutic process.
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"}}
Explanation
Indicates potential Improvement a. Hygiene b. Food intake c. Rapid change in mood
Indicates potential worsening a. Giving away car b. Condition of skin on right hand
Choice A: Giving away car
This could be a sign of the client’s worsening condition. Giving away possessions can sometimes be a sign of suicidal ideation. It’s important to monitor this behavior and report it to the healthcare provider.
Choice B: Hygiene
The client showered without prompting on the third day, which is an improvement from the first day when they declined to shower. Improved personal hygiene can be a sign of improvement in a client with obsessive-compulsive disorder.
Choice C: Food intake
The client ate 75% of their meals on the third day, which is an improvement from the first day when they refused to eat. Increased food intake can indicate an improvement in the client’s condition2.
Choice D: Condition of skin on right hand
The client’s hands remain reddened with a 1 cm x 1 cm area of peeling skin noted on the center of the right palm. This could indicate a worsening condition, as it may be a result of excessive handwashing, a common compulsion in OCD.
Choice E: Rapid change in mood
The client’s affect rapidly changed throughout the afternoon and early evening; the client is now talkative and appears content. This could indicate an improvement in the client’s condition, as they are engaging more with others and showing more positive emotions.
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