A nurse is caring for a client who was admitted to an acute care mental health facility for treatment of borderline personality disorder. The client leaves her current activity, approaches the nurse and states, "There's no reason to go on living. I just want to end it all." Which of the following nursing interventions is appropriate?
Ask the client if she has a plan to commit suicide.
Recognize the attempt at manipulation and escort the client back to her activity.
Assist the client to her room and allow her to rest before resuming activity.
Notify the client’s family and request a visitor to stay with the client until thoughts of suicide are gone.
The Correct Answer is A
Choice A reason: Asking if the client has a plan to commit suicide is the priority intervention. It directly assesses the level of risk and helps determine the immediacy of danger. Suicide risk assessment is essential in borderline personality disorder, where impulsivity and self-harm are common.
Choice B reason: Assuming manipulation dismisses the seriousness of suicidal ideation. Even if manipulation is suspected, all suicidal statements must be taken seriously to ensure safety.
Choice C reason: Allowing the client to rest does not address the risk of suicide. Safety assessment must occur before any other intervention.
Choice D reason: Notifying family may be supportive but is not the immediate priority. The nurse must first assess the client’s risk and ensure safety before involving others.
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Related Questions
Correct Answer is C
Explanation
Choice A reason: Parkinson-like symptoms such as tremors and rigidity are associated with pseudoparkinsonism, not tardive dyskinesia.
Choice B reason: Muscle pain and spasms are more consistent with acute dystonia, not tardive dyskinesia.
Choice C reason: Tardive dyskinesia is characterized by permanent, involuntary movements, often of the face, tongue, and extremities. These movements are a late and often irreversible side effect of long-term antipsychotic use.
Choice D reason: Severe restlessness is akathisia, a different extrapyramidal side effect.
Correct Answer is B
Explanation
Choice A reason: An overly friendly attitude may increase suspicion in a client with paranoia. A calm, neutral approach is more therapeutic.
Choice B reason: Allowing the client to unwrap food items helps reduce paranoia about tampering or poisoning. This intervention promotes trust and reduces anxiety.
Choice C reason: Using touch can be misinterpreted and increase paranoia or agitation. Physical contact should be avoided unless necessary for safety.
Choice D reason: Rotating staff frequently can increase mistrust. Consistency in caregivers helps build rapport and reduce paranoia.
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