A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

The client is experiencing withdrawal symptoms.

The client is experiencing hallucinations.

The client is at risk for traumatic re-experiencing.

The client is at risk for self-harm or harm to others.

Answer and Explanation

The Correct Answer is D

Choice A reason:
The client experiencing withdrawal symptoms should be monitored, as these symptoms can range from mild to severe. Withdrawal symptoms may include fatigue, depression, and anxiety, which are significant but generally not life-threatening. The nurse should provide supportive care and monitor the client's vital signs and emotional state.

Choice B reason:
If the client is experiencing hallucinations, this indicates a more severe level of withdrawal and possibly the presence of a stimulant-induced psychotic disorder. While hallucinations can be distressing and require intervention, they are not the highest priority when compared to the risk of self-harm or harm to others.

Choice C reason:
The risk for traumatic re-experiencing, or flashbacks, is a concern during withdrawal, particularly if the client has a history of trauma. These experiences can be highly distressing and may lead to further psychological distress. However, the immediate physical safety of the client and others takes precedence.

Choice D reason:
The risk of self-harm or harm to others is the most critical safety concern and must be prioritized. Clients withdrawing from stimulants may exhibit increased agitation, aggression, or impulsivity, which can lead to dangerous behaviors. The nurse must take immediate action to ensure a safe environment, which may include close supervision, the use of restraints, or rapid pharmacological intervention.

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Correct Answer is D

Explanation

Choice A reason:
Identifying the client's support systems is an important aspect of the assessment, as support systems can play a crucial role in the client's recovery. However, it is not the highest priority during the initial assessment. Support systems can provide emotional, social, and sometimes financial assistance, which can be beneficial in managing a situational crisis.

Choice B reason:
Identifying the client's coping skills is also important because it helps the nurse understand how the client typically deals with stress and crises. Coping skills are mechanisms that individuals use to manage stressful situations and can include problem-solving, seeking support, and using relaxation techniques. However, this is not the highest priority during the initial assessment.

Choice C reason:
Asking the client to identify the cause of the crisis can provide valuable information about the client's perspective and insight into the situation. Understanding the cause can help in planning appropriate interventions. However, this is not the highest priority during the initial assessment, especially if the client is not in a stable condition to discuss the crisis.

Choice D reason:
Determining if the client has psychotic thinking, is the highest priority. Psychotic thinking can include delusions, hallucinations, and disorganized thoughts, which may indicate a severe mental health condition that requires immediate attention. It is essential to assess for psychotic symptoms to ensure the safety of the client and others, as well as to determine the need for urgent psychiatric intervention.

A. Give the family an opportunity to talk about their feelings. B. Investigate and identify cues in the client's behavior that might have indicated contemplation of suicide. C. Provide professional counseling for staff members. D. Change policies for staff observation of clients who are suicidal.

Correct Answer is C

Explanation

Choice A reason:
While giving the family an opportunity to talk about their feelings is important, it is not the immediate priority for staff intervention following the incident. The family's needs are crucial, but the question specifically asks about the staff's follow-up actions.

Choice B reason:
Investigating and identifying cues in the client's behavior that might have indicated contemplation of suicide is a critical step in understanding and preventing future incidents. However, this is more of a retrospective action and not the immediate priority for staff intervention after such an event.

Choice C reason:
Providing professional counseling for staff members is the priority intervention. Staff members may experience a range of emotions, including grief, guilt, and trauma, following a client's suicide. Professional counseling can support staff in processing these feelings and prevent potential long-term psychological effects.

Choice D reason:
Changing policies for staff observation of clients who are suicidal may be necessary, but it is not the immediate priority following the incident. Policy review and changes are part of a longer-term strategy to improve care and prevent future incidents.

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A nurse is caring for a client who is withdrawing from a stimulant. Which of the following should be prioritized for safety in a client with stimulant withdrawal?

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