A young-adult client is admitted to the psychiatric unit because of a recent suicide attempt. The client's spouse filled for divorce six months ago, the client lost a job three months ago, and the best friend moved to another city two weeks ago. Which intervention should the nurse include in this client's plan of care?

Allow the client time alone to sort out any feelings.

Avoid discussing subjects that upset the client.

Encourage activities that allow the client to exert control over the client's environment.

Encourage the client to interact with persons who are recovering from depression.

Answer and Explanation

The Correct Answer is C

A) Allowing the client time alone to sort out feelings may seem supportive, but isolation can be detrimental, especially for someone who has recently attempted suicide. Social withdrawal can exacerbate feelings of despair and hopelessness. Instead, encouraging engagement with others and structured activities is often more beneficial.

B) Avoiding discussions about subjects that upset the client can lead to avoidance coping and prevent the client from processing important emotions. While it’s important to be sensitive to triggers, avoiding difficult topics may hinder therapeutic progress. Open dialogue is essential for healing and understanding.

C) Encouraging activities that allow the client to exert control over their environment is an effective intervention. This approach helps rebuild a sense of agency and empowerment, which is crucial for clients who may feel helpless after experiencing significant losses. Engaging in structured activities can foster a sense of accomplishment and stability, which can be particularly beneficial for someone recovering from a suicide attempt.

D) Encouraging the client to interact with persons who are recovering from depression can provide valuable support and understanding; however, this may not be the most immediate intervention. The client may still be in a fragile state, and facilitating control through structured activities might be a more effective way to build confidence and a sense of community before introducing peer interactions.

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Correct Answer is C

Explanation

A) Listening to what the client is saying can be important for understanding their perspective, but in this situation, the client's loud and wild behavior may be disruptive or alarming to others. Prioritizing safety is crucial.

B) Sitting in the chair next to the client could help establish rapport, but it does not address the immediate need to manage the disruptive behavior. The nurse must first ensure a safe environment for all clients.

C) Escorting the client to his room is the best initial action. This intervention helps to remove the client from the potentially stimulating environment of the day room, reducing the likelihood of escalation and providing a quieter space where the client can feel more secure and calm. It also minimizes disruption to other clients.

D) Administering a PRN sedative may be necessary if the behavior continues to escalate, but it should not be the first action taken. Non-pharmacological interventions, such as providing a safe space, should be prioritized before considering medication.

A. Tell me what you think should happen. B. Call for transportation to the hospital. C. How serious was the collision D. What do you think you should do?

Correct Answer is B

Explanation

A) Asking the employee what she thinks should happen may put additional pressure on her during an extremely distressing moment. In a crisis, individuals often struggle to think clearly, and this response may not provide the immediate support she needs.

B) Calling for transportation to the hospital is the best response. This action demonstrates immediate support and concern for her well-being and allows her to prioritize reaching her child. It provides practical assistance in a moment of crisis and helps ensure she can get to her child as quickly as possible.

C) Asking how serious the collision was may seem relevant, but it could increase anxiety for the employee. She may not have this information, and discussing the severity of the situation could lead to further distress when she is already overwhelmed.

D) Asking what she thinks she should do could also add pressure to make a decision at a time when she is likely feeling helpless and confused. In a crisis, offering direct support and assistance is typically more effective than seeking input from the individual.

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Naxlex Comprehensive Predictor Exams

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit's day room. Which action should the nurse implement first?

Correct Answer is C

Explanation

The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle collision and taken to the hospital. The employee states, 1 can't believe this. What should I do? Which response is best for the nurse to provide in this crisis?

Correct Answer is B

Explanation

The nurse is admitting a client who has not slept in three days to the inpatient care facility. The client has pressured speech and describes an increase in sexual promiscuity. Which problem should the nurse include in the client's plan of care?

The mental health nurse observes that a female client with delusional disorder carries some of her belongings with her because she believes that others are trying to steal them. Which nursing action will promote trust?

The nurse is providing care for a client diagnosed with a borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the nurse use when changing this client's dressings?

A female client admitted to the mental health unit starts to shout and scream at the nurse. Which is the best approach for the nurse to take?