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."

Answer and Explanation

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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Correct Answer is B

Explanation

Choice A reason: Asking "Why did you feel like giving away your belongings?" could be perceived as confrontational or judgmental. It's important to approach the client with empathy and without implying that their actions were wrong or require justification.

Choice B reason: "Can you tell me how you have been feeling lately?" is an open-ended question that invites the client to share their feelings and experiences. It demonstrates the nurse's interest in understanding the client's emotional state and provides a safe space for the client to express themselves.

Choice C reason: Saying "Everyone feels a little down sometimes." minimizes the client's experience and the severity of major depressive disorder. It fails to acknowledge the unique and serious nature of the client's condition.

Choice D reason: While suggesting "You should find a support group to attend." can be helpful, it may be more appropriate after establishing a rapport and understanding the client's current state. It's also important to offer support in finding resources rather than directing the client.

A. "Take a 1-hour nap every day." B. "Exercise late in the day, preferably before bedtime." C. "Keep a sleep diary to promote a consistent sleep schedule." D. "Discontinue any medication until your sleep disruption is addressed."

Correct Answer is C

Explanation

Choice A reason: Taking a 1-hour nap every day is not recommended for individuals with sleep disruptions, especially due to depressive disorder, as it can further disrupt nighttime sleep patterns.

Choice B reason: Exercising late in the day can be stimulating and may make it harder to fall asleep. It is generally advised to exercise earlier in the day to improve sleep quality.

Choice C reason: Keeping a sleep diary is a beneficial intervention for individuals with sleep disruptions. It can help identify patterns and behaviors that affect sleep and is a step towards establishing a consistent sleep schedule.

Choice D reason: Discontinuing medication without medical advice is not safe. Medications for depressive disorder should be managed by a healthcare provider, especially as abrupt changes can have serious consequences.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has major depressive disorder and states that they have given away their personal belongings. Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a client who has a depressive disorder. The client states, "I don't always go to bed at night, so I get in trouble for falling asleep at work." Which of the following interventions should the nurse recommend?

Correct Answer is C

Explanation

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