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. This is not the primary reason for the counseling. The decision-making recommendation is
more related to the effects of the electroconvulsive therapy and the need for the patient to recover from its associated side effects.
B. While readjustment to a work schedule might be a consideration, the primary reason for counseling against major decisions for a month is related to the potential side effects of
electroconvulsive therapy.
C. Temporary memory impairments and confusion are potential side effects of electroconvulsive therapy, which might interfere with decision-making abilities, hence the advice to refrain from major decisions.
D. Antidepressant medications causing confusion related to dietary limitations with tyramine is not directly relevant to the counseling against making major decisions after electroconvulsive therapy.

A. Patient is attempting to use relaxation strategies. B. Patient is demonstrating withdrawal behaviors. C. Patient is exhibiting clues to potential aggression. D. Patient is trying to work through angry feelings.

Correct Answer is C

Explanation

A. Relaxation strategies involve deliberate and often structured activities aimed at reducing tension and stress, which isn't depicted in the described behavior.
B. Withdrawal behaviors typically involve avoiding social interaction or retreating, which doesn't align with the observed actions.
C. The described behavior, including pacing, clenching fists, and staring at a staff member, indicates potential signs of aggression or agitation.
D. Working through angry feelings might involve communication or expression of emotions, but the described behavior leans more towards agitation and potential aggression.

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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

Correct Answer is C

Explanation

Correct Answer is C

Explanation

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hr hold is over for which of the following conditions?

When considering an individual's risk for suicide, which client will the nurse consider the priority?

What is the primary difference between somatic system disorders and dissociative disorders?

How does a psychiatric nurse best implement the ethical principle of autonomy?

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A nurse teaching a patient about a tyramine-restricted diet would approve which meal?

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding of the teaching?