A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is C

Explanation

explanation:

Adult day care facilities provide a safe and supervised environment for older adults during the day, while their family members or caregivers are at work or unable to be present. These facilities offer various activities, social interactions, and personal care services to support the needs of individuals with dementia and other conditions. Attending an adult day care facility canalso give the client an opportunity to engage with others and maintain cognitive and physical stimulation.

A- Hospice care is generally recommended for individuals with terminal illnesses who are nearing the end of life. It focuses on providing comfort and support to the patient and family during the end-of-life journey.

B- Long-term care facilities may be appropriate for some individuals with advanced dementia who require round-the-clock care and supervision. However, in this scenario, the client's adult child is present and working full time, suggesting that the family intends to provide care at home as much as possible.

D- Community senior centers may offer various activities and programs for older adults, but they may not provide the level of supervision and care required for an individual with early onset dementia during the day, especially if their family member is at work.

A. "Sleep longer hours on the weekend." B. "Keep the television volume low while you are trying to fall asleep." C. "Establish a daily exercise routine." D. "Remain in bed until you fall asleep."

Correct Answer is C

Explanation

Regular physical exercise has been shown to promote better sleep. Engaging in daily exercise can help regulate the sleep-wake cycle, promote relaxation, reduce anxiety and stress, and increase overall sleep quality. It is important to note that exercise should ideally be done earlier in the day, at least a few hours before bedtime, as exercising too close to bedtime may actually have a stimulating effect and make it harder to fall asleep.

The other options listed are not the most appropriate recommendations for addressing difficulty in falling asleep:

"Sleep longer hours on the weekend." This suggestion may disrupt the client's sleep routine and can lead to inconsistent sleep patterns throughout the week, potentially making it more challenging to fall asleep on subsequent nights.
"Keep the television volume low while you are trying to fall asleep." It is generally recommended to create a sleep-friendly environment, which includes reducing external stimuli like noise, light, and electronic devices in the bedroom. However, watching television right before bedtime can interfere with sleep as the bright light and stimulating content can keep the mind awake.
"Remain in bed until you fall asleep." This recommendation may contribute to increased frustration and anxiety if the client is unable to fall asleep quickly. It is generally advised to practice good sleep hygiene, which includes getting out of bed if unable to fall asleep after a reasonable amount of time and engaging in a relaxing activity until feeling sleepy again.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

Nursing Test Bank

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