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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Restraining the client should be a last resort and is not the initial action to take when managing an agitated client.
B. Seclusion should also be considered as a last resort, and de-escalation techniques should be attempted before secluding the client.
C. Speaking calmly and providing simple directions can help de-escalate the situation by promoting a calm environment and reducing stimuli that may exacerbate the client's agitation.
D. While medication might be necessary in some cases, it's not the first action to take when a client becomes agitated.
Correct Answer is D
Explanation
A. Avoiding exposure to bright sunlight is not specifically related to SSRIs; it may be a
consideration with certain medications due to photosensitivity but isn't a primary concern with SSRIs.
B. Restricting sodium intake isn't a directive associated with SSRI antidepressant therapy.
C. Maintaining a tyramine-free diet is a concern with certain antidepressants like MAOIs (Monoamine Oxidase Inhibitors) but not typically with SSRIs.
D. Reporting increased suicidal thoughts is a crucial directive because SSRIs may initially increase the risk of suicidal ideation, especially in the early stages of treatment.
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.
