Which of the following principles should the nurse apply when planning nursing care for a client who was admitted after a suicide attempt?
Clients who talk about suicide are less likely to attempt it
Clients who attempt suicide and fail will not try again
Clients who attempt suicide and fail did not really want to die
The more specific the plan, the greater the risk of suicide
The Correct Answer is D
Choice A reason: The belief that clients who talk about suicide are less likely to attempt it is a myth. Verbalizing suicidal ideation often reflects severe distress and heightened risk, as it may indicate prefrontal cortex dysfunction and impaired impulse control. This misconception underestimates the neurobiological basis of suicidal behavior, requiring vigilant assessment.
Choice B reason: Assuming clients who fail a suicide attempt will not try again is incorrect. Previous attempts increase future risk, as suicidal behavior is linked to persistent psychological distress and serotonin dysregulation. This assumption ignores the chronicity of underlying conditions like depression, necessitating ongoing monitoring and intervention to prevent recurrence.
Choice C reason: Claiming failed suicide attempts indicate a lack of intent to die is false. Many attempts fail due to external factors, not lack of intent. Suicidal behavior reflects complex neurobiological factors, including serotonin imbalance and prefrontal cortex deficits, requiring serious intervention regardless of outcome, as intent persists in high-risk individuals.
Choice D reason: A specific suicide plan indicates high risk, as it reflects advanced ideation and intent, often linked to prefrontal cortex dysfunction and reduced impulse control. Detailed planning suggests the client has visualized the act, increasing likelihood of completion. This principle guides nursing care to prioritize safety and immediate psychiatric intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
ideation, as some clients express relief anticipating death. While concerning, it is less specific than other indicators, as it may not always reflect serotonin-driven despair or intent, requiring further assessment to confirm risk.
Choice B reason: Feeling overwhelmed by simple tasks indicates severe depression, linked to serotonin and prefrontal cortex dysfunction, impairing executive function. This heightens suicidal risk, as cognitive overload and hopelessness increase impulsivity and despair, making it a critical neurobiological marker requiring immediate intervention to prevent self-harm.
Choice C reason: Calling family to make amends signals high suicidal risk, often reflecting intent to resolve relationships before death, driven by serotonin dysregulation and prefrontal cortex deficits. This behavior indicates advanced planning, a neurobiological marker of serious ideation, necessitating urgent safety measures to prevent completion.
Choice D reason: An abrupt mood improvement can indicate suicidal risk, as it may reflect relief from deciding to end life, linked to serotonin and dopamine shifts. This neurobiological change reduces despair temporarily, increasing energy for action, making it a critical warning sign requiring immediate assessment and intervention.
Correct Answer is C
Explanation
Choice A reason: Phenytoin, an anticonvulsant, is not routinely given before ECT, as the procedure induces controlled seizures to stimulate brain activity, treating depression via neurochemical changes. Administering phenytoin would inhibit seizure activity, reducing ECT efficacy by blocking neuronal excitability, making this an inappropriate action for the procedure.
Choice B reason: Instructing about post-ECT headaches is valid, as they result from cerebral vasoconstriction or muscle tension during seizures. However, this is a post-procedure expectation, not a priority action during planning. Monitoring cardiac rhythm takes precedence, as ECT’s autonomic stimulation poses immediate cardiovascular risks requiring real-time management.
Choice C reason: Monitoring cardiac rhythm during ECT is critical, as the procedure induces seizures that stimulate the autonomic nervous system, causing transient tachycardia or arrhythmias due to catecholamine surges. These can exacerbate underlying cardiac conditions, risking instability. Continuous monitoring ensures early detection and management of cardiovascular complications, prioritizing patient safety.
Choice D reason: Four-point restraints are not used in ECT, as patients are under general anesthesia, preventing movement. Restraints risk injury and are unnecessary, as muscle relaxants like succinylcholine minimize convulsive movements. This approach contradicts ECT’s controlled, anesthetized protocol, making it inappropriate for ensuring safety during the procedure.
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