Which of the following is the priority action by the nurse for a client with symptoms of depression who admits to thoughts of self-harm with a plan, and has a history of borderline personality disorder, depression, and substance abuse?
Review the client's toxicology laboratory report.
Initiate suicide precautions.
Administer the Hamilton Depression Scale.
Make a contract with the client for behavior in the unit.
The Correct Answer is B
Choice A reason:
While reviewing the client's toxicology laboratory report is important to understand any substance use that may be contributing to the client's current state, it is not the immediate priority. The priority is to ensure the client's safety.
Choice B reason:
Initiating suicide precautions is the most critical and immediate action when a client admits to thoughts of self-harm with a plan. This involves creating a safe environment, providing constant supervision, and possibly removing harmful objects to prevent the client from acting on these thoughts.
Choice C reason:
Administering the Hamilton Depression Scale can help in assessing the severity of depression, but it is not the first priority. The immediate concern is to protect the client from self-harm.
Choice D reason:
Making a contract with the client for behavior in the unit can be a useful part of the treatment plan, particularly for clients with borderline personality disorder. However, it is not the first action to take when a client is at immediate risk for self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Hallucinations are not a common side effect of Buspar (Buspirone) and could indicate a serious reaction to the medication. If a client experiences hallucinations, it is crucial for the nurse to report this to the provider immediately as it may require medical intervention or adjustment of the medication.
Choice B reason:
Discolored urine can be concerning, but it is not typically associated with Buspar (Buspirone). It could be related to other factors such as diet, hydration levels, or other medications. However, if the discoloration is persistent or accompanied by other symptoms, it should be reported to the provider.
Choice C reason:
Decreased appetite might occur with Buspar (Buspirone), but it is generally not considered a serious side effect. If the decreased appetite leads to significant weight loss or nutritional deficiencies, it should be discussed with the provider.
Choice D reason:
Sweating can be a side effect of many medications and is not usually a cause for concern with Buspar (Buspirone). However, if sweating is excessive or causes discomfort, it may be worth mentioning to the provider.
Correct Answer is C
Explanation
Choice A reason:
Documenting the client's verbatim statements is crucial for legal purposes and for ensuring that the client's experience is accurately recorded. However, this is not the first action to take. The nurse must first address any immediate medical concerns, which include identifying and treating injuries.
Choice B reason:
Asking for permission to take photographs is an important part of collecting evidence, but it should be done after addressing immediate health concerns and with the client's consent. It is also essential that this step is performed in a sensitive and non-judgmental manner.
Choice C reason:
Determining any physical signs of injury is the most critical initial step. The nurse must assess for injuries that may require immediate intervention. This aligns with the priorities of care in emergency nursing, which focus on stabilizing the patient's condition and addressing urgent health issues.
Choice D reason:
Providing community sexual assault support contacts is an important aspect of holistic care and ensures that the client has access to ongoing support. However, this action follows after immediate health concerns have been addressed and should be part of the long-term care plan.
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