The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Alert the assigned staff to closely monitor client and intervene as needed to reduce risk of selfmutilation.

Provide the client time alone in the client's room to reduce external stimulation and promote relaxation.

Give the client firm, consistent expectations that self-mutilating behaviors are unacceptable and will not be allowed.

Complete a thorough room search to ensure the client does not have access to objects that can be used for self-harm.

Answer and Explanation

The Correct Answer is A

A. The client's increased body tension and pacing indicate escalating distress and potential risk for self-harm. Alerting staff to closely monitor the client and intervene as needed is crucial to ensure the client's safety.
B. Providing time alone in the client's room may be appropriate in some situations but may not address the immediate risk of self-mutilation if the client is experiencing escalating distress. C. Giving firm, consistent expectations about self-mutilating behaviors is important for establishing boundaries, but it may not be sufficient to address the immediate risk of self-harm without additional monitoring and intervention.
D. Completing a thorough room search is important for safety but may not address the immediate risk of self-harm if the client is already exhibiting signs of distress and pacing in the hallway.

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Correct Answer is D

Explanation

A. Ventilating emotions when distressed may be helpful in some situations, but it may not directly address the client's avoidance behavior or assist in building coping skills to manage responsibilities.
B. Relaxing and reducing effort to solve problems may exacerbate feelings of helplessness and avoidance, rather than promoting active coping strategies.
C. Shifting attention from self to the needs and requests of others may be beneficial in certain contexts, but it may not directly address the client's depressive symptoms or avoidance behavior.
D. Focusing on small achievable tasks allows the client to experience a sense of accomplishment and mastery, which can help counteract feelings of helplessness and build confidence in managing responsibilities. This approach aligns with behavioral activation techniques commonly used in the treatment of depression.

A. A retired older male whose significant other has passed away. B. A nurse who works in a pediatric emergency department. C. An adolescent male whose parents recently divorced. D. A single working mother with three pre-school aged children.

Correct Answer is C

Explanation

A. While the loss of a significant other can be a risk factor for suicide, retired older males may have developed coping mechanisms over time that could mitigate the risk.
B. While working in a pediatric emergency department can be stressful, it does not necessarily indicate a higher risk for suicide compared to other factors such as personal life stressors or mental health issues.
C. Adolescents experiencing significant life changes such as parental divorce are at increased risk for suicide due to the emotional upheaval and lack of coping skills typical of this age group.

D. While being a single working mother with three preschool-aged children can be stressful, it does not inherently indicate a higher risk for suicide compared to other factors such as social support, coping mechanisms, and mental health status.

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The nurse notes that a client with a history of self-mutilation has increased body tension and is pacing in the hallway. Which nursing intervention is most important at this time?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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