A nurse is evaluating a client who threatens suicide. The nurse’s primary responsibility to the client is to provide a safe, therapeutic environment. Which nursing intervention is most effective in establishing a safe environment for the client?
Keep the client involved in structured activities with other clients as directed by the staff.
Assign a staff member to stay with the client and provide constant observation.
Place the client in a seclusion room designed to minimize stimulation.
Remove all potential items that could assist the client in committing suicide.
The Correct Answer is B
Managing clients at acute risk of suicide involves creating a safe, controlled environment where self-harm is impossible. Constant observation is essential for high-risk individuals, especially during acute phases. Removing dangerous objects is necessary but secondary to direct monitoring. Early intervention reduces impulsivity and provides immediate emotional support.
Rationale for correct answers
B. Constant observation and safety assurance are crucial when a client is actively suicidal, providing immediate response to any self-harm attempt and fulfilling physiological safety needs.
Rationale for incorrect answers
A. Structured group activities may help later in treatment but are insufficient alone to protect actively suicidal clients.
C. Seclusion may increase distress and is not a first-line response unless the client is aggressive or cannot be managed through less restrictive means.
D. While removing harmful items is necessary, it does not provide continuous monitoring, which is essential for high-risk clients.
Take Home Points
- Active suicide risk requires constant observation.
- Safety measures must address both physical and emotional needs.
- Seclusion is not routine and should be used cautiously.
- Removal of dangerous items is helpful but not a substitute for supervision.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Operant conditioning reinforces behaviors through consequences. In positive reinforcement, a desirable behavior is followed by a reward to increase recurrence. This is commonly used in treating substance use disorders, where praise or tangible rewards encourage sobriety.
Rationale for correct answers
B. Behavioral reinforcement through praise encourages continued abstinence, increasing desired behavior frequency.
Rationale for incorrect answers
A. Administering consequences is punishment, not positive reinforcement.
C. Taking away privileges is negative punishment.
D. Ignoring behavior is extinction, not reinforcement.
Take Home Points
- Positive reinforcement encourages repeated behavior.
- Praise for sobriety is effective in addiction recovery.
- Operant conditioning is foundational in behavior therapy.
- Reinforcement must be timely and meaningful.
Correct Answer is A
Explanation
Cognitive therapy aims to identify and modify distorted thinking patterns that lead to dysfunctional emotions and behaviors. It focuses on the present, is highly structured, and emphasizes reality testing of beliefs. This therapy is effective for depression, anxiety, and personality disorders, and often includes homework assignments to reinforce learning.
Rationale for correct answers
A. Thought identification and correction are central to cognitive therapy’s goal of improving emotional regulation through mental restructuring.
Rationale for incorrect answers
B. Insight into unconscious conflict is associated with psychoanalysis, not cognitive therapy.
C. Coping improvement is a secondary effect, not the direct goal.
D. Behavior change is part of CBT, but cognitive therapy specifically targets thinking.
Take Home Points
- Cognitive therapy targets how thoughts affect emotions.
- It focuses on present thinking, not past experiences.
- Distorted beliefs are identified and challenged.
- It's effective for a range of mood and anxiety disorders.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.