A nurse on a mental health unit is planning care for a client who has a new diagnosis of non- suicidal self-harm (NSSH). Which of the following interventions should the nurse include in the plan?
Explain to the client that self-harm behaviors do not increase their risk for accidental death.
Inform the client that self-harm behavior cannot become a serious problem in the future.
Encourage the client to identify the emotions they feel immediately before performing the self- harm behavior.
Place the client in one-on-one direct observation due to overt suicidal intent.
The Correct Answer is C
C Encouraging the client to identify the emotions they feel immediately before performing the self-harm behavior is an important intervention. It can help the client develop insight into triggers and underlying emotions that contribute to the behavior. Identifying and addressing these emotions can be a crucial step in developing healthier coping mechanisms.
A. It is crucial to convey the potential risks associated with self-harm and emphasize the importance of seeking help and safer coping strategies.
B. Non-suicidal self-harm is a significant concern that requires attention and appropriate intervention. While NSSH does not necessarily indicate immediate suicidal intent, it can indicate significant distress
D. NSSH does not necessarily indicate suicidal intent, and placing the client in constant observation without clinical justification may be intrusive and undermine therapeutic rapport.
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Related Questions
Correct Answer is D
Explanation
D. It emphasizes the importance of addressing the client's immediate emotional and psychological needs. Reassurance and comfort can help alleviate the client's distress and promote a sense of security, which is essential for their well-being.
A. Participation in group activities may be beneficial for some clients with schizophrenia but it is not the priority when the client is experiencing confusion and distortions in thinking.
B. Medication management is an important aspect of caring for clients with schizophrenia. However, the decision to administer PRN medications should be based on a comprehensive assessment of the client's symptoms and needs.
C. Distraction techniques may be helpful for managing symptoms of anxiety or agitation in some clients, but they are not the priority.
Correct Answer is A
Explanation
A. Acute toxicity to sedatives, especially at high doses, can lead to various central nervous system effects, including severe hallucinations. Hallucinations can involve distorted perceptions of sensory experiences, such as seeing, hearing, or feeling things that are not present. These hallucinations may be vivid, intense, and disturbing, especially during acute intoxication.
B. Negative symptoms are more commonly associated with chronic psychotic disorders like schizophrenia rather than acute toxic reactions.
C. Prolonged hallucinations are less characteristic of acute toxicity and are more commonly seen in conditions like schizophrenia or certain drug-induced psychotic disorders.
D. Prolonged delusions typically characterize chronic psychotic disorders rather than acute toxic reactions.
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