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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Moderate level would suggest a plan that has some risk but may be less imminent or less likely to result in death.
B. A plan involving a loaded gun aimed at a vital organ like the heart, coupled with alcohol consumption and intent, indicates a high level of lethality.
C. This scenario presents a significant risk given the method and the caller's intent, so "No risk" would not be appropriate.
D. Low level would suggest a plan that is less likely to cause severe harm or death, which is not the case here.
Correct Answer is C
Explanation
A. Sleep disturbances are common in PTSD, but they might not address the current acute symptoms the client is experiencing.
B. This question explores the immediate trigger for an outburst but might not directly address the PTSD symptoms related to the sexual assault.
C. Inquiring about flashbacks directly relates to one of the hallmark symptoms of PTSD, especially given the recent severe anxiety related to the assault.
D. Avoidance behavior is a symptom of PTSD, but the question about experiencing a flashback addresses more immediate distress.
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