A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

Allow no glass or metal on meal trays.

Check the patient's whereabouts every 15 minutes and make frequent verbal contact.

Remove all potentially harmful objects from the patient's possession.

Maintain arm's length, one-on-one nursing observation around the clock.

Answer and Explanation

Correct Answer : A,B,C

A.   This precaution helps eliminate potential means for self-harm.
B.   Regular checks and verbal contact are essential to monitor the patient's safety and provide support.
C.   Removing objects that could be used for self-harm is a key part of suicide precautions.
D.   While this is an intensive level of observation, it might not be feasible at all times due to staffing limitations, making this choice less practical than the others.

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Correct Answer is C

Explanation

A. While assessing the impact of a suicide attempt on others is important, the immediate focus following a successful suicide attempt in a mental health unit is to ensure the safety of all clients.
B. Restricting group therapy for 72 hours might impede the therapeutic process and does not directly address the safety of clients after a suicide attempt.
C. Following a suicide attempt, it's standard practice to heighten monitoring and implement suicide precautions for all clients to ensure their safety.
D. While assessing the situation is important, immediate intervention to prevent further harm to other clients is a priority following a suicide attempt. The psychological assessment might occur but would not be the primary intervention in this immediate crisis situation.

A. "Let's talk about something else because this subject is upsetting you." B. "I can see that you feel sad about this situation." C. "Crying is a way of expressing the hurt you're experiencing." D. "The loss of your parent is very painful for you."

Correct Answer is ["B","C","D"]

Explanation

A. This response invalidates the patient's feelings and avoids addressing the emotion, hindering communication.
B. Acknowledging the patient's emotion validates their feelings and encourages further discussion.
C. Validates the patient's emotional expression and offers understanding.
D. Acknowledges the depth of the patient's pain and encourages expression without judgment.

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A patient with suicidal impulses is on the highest level of suicide precautions. Which measures should the nurse incorporate into the patient's plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has made a successful suicide attempt while hospitalized on a unit that specializes in the treatment of depression. When considering both milieu control and crisis management, which intervention will the nursing staff implement?

Correct Answer is C

Explanation

A patient cries as the nurse explores the patient's relationship with a deceased parent. The patient says, "I shouldn't be crying like this. It happened a long time ago." Which responses by the nurse will facilitate communication? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

Which intervention(s) should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)

An individual has been diagnosed with a dissociative disorder. Which comorbid psychiatric disorders are most likely to accompany this type of mental illness? (Select all that apply.)

A patient diagnosed with major depressive disorder begins selective serotonin reuptake inhibitor (SSRI) antidepressant therapy. Priority information given to the patient and family should include a directive to do what?

A nurse in an acute mental health facility is caring for a client who jumps out of her chair and begins to shout angrily at the clients around her. Which of the following actions should the nurse take first?

A nurse is performing an admission assessment for a client who is receiving treatment following a situational crisis. Which of the following assessments by the nurse is the highest priority?

After failing two tests, a college student cried for hours and then tried to telephone a parent but got no answer. The student then gave several expensive sweaters to a roommate. Which behavior provides the strongest clue of an impending suicide attempt?

When assessing for the subjective symptoms of posttraumatic stress disorder (PTSD), which question will the nurse ask a client hospitalized for severe anxiety related to a sexual assault by a family member as a teenager?

A nurse interacts with a newly hospitalized patient. Which nursing statement reflects the communication technique of "offering self"?