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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Dementia is characterized by progressive memory impairment, including difficulty remembering recent events, names, and familiar faces. This memory loss can significantly impact the client's ability to perform daily tasks independently.
While dementia is typically a chronic and progressive condition, it is not uncommon for individuals with dementia to experience acute episodes of confusion, often referred to as "sundowning." These episodes tend to occur in the late afternoon or evening and can involve increased agitation, restlessness, and disorientation.
Illusions are perceptual distortions where a person misinterprets real sensory stimuli. In dementia, individuals may experience illusions, such as mistaking a coat hanging on a door for a person or misinterpreting shadows as threatening figures.
Catatonia, characterized by immobility and unresponsiveness, is not typically associated with dementia. It is more commonly seen in conditions such as schizophrenia or certain neurological disorders.
Correct Answer is B
Explanation
Valid and reliable health information sources should provide references or citations to support the information they present. This demonstrates that the information is based on evidence and has been reviewed by experts in the field. It allows readers to verify the accuracy and reliability of the information by referring to the cited sources.
The author's name listed without credentials does not provide information about the author's expertise or qualifications. It is important to assess the author's credentials and expertise to determine their credibility.
The website URL being listed as .com does not provide information about the accuracy or reliability of the content. Different types of websites, such as .org or .gov, can also contain credible health information.
The website being last updated 3 years ago raises concerns about the currency and relevance of the information. Health information can quickly evolve, and it is important to access up-to-date resources.
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