While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

The client displays agitation.

The client becomes suddenly cheerful.

The client experiences psychomotor retardation.

The client does not attend group therapy.

Answer and Explanation

The Correct Answer is B

A.   Agitation can be a sign of distress, but sudden cheerfulness may be indicative of a decision to act on suicidal thoughts, as the individual may feel relieved to have made a decision.
B.   Sudden cheerfulness can be a concerning sign, as it may indicate that the client has made a decision to carry out suicidal thoughts.
C.   Psychomotor retardation is a symptom of depression and may not necessarily indicate imminent risk of suicide.
D.   Not attending group therapy may be a sign of withdrawal or isolation, but it does not directly indicate immediate suicidal risk.

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Correct Answer is D

Explanation

A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.

A. Plan to discuss any topic that is presented. B. Focus on client weaknesses to increase adaptation. C. Provide continuity of care by assigning the same staff. D. Allow client to determine the boundaries of the nurse client relationship.

Correct Answer is C

Explanation

A) Incorrect. While discussing various topics is important, providing continuity of care is more crucial in creating a therapeutic environment for clients with paranoia and schizophrenia.

B) Incorrect. Focusing on client strengths rather than weaknesses is generally a more effective approach in mental health care.

C) Correct. Providing continuity of care by assigning the same staff helps build trust and a sense of security for clients, especially those with paranoia and schizophrenia.
D) Incorrect. While it's important to establish boundaries, allowing the client to solely determine them may not always be in their best interest.

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While caring for a depressed client, a nurse would evaluate the need for suicide precautions under which circumstance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?

Correct Answer is D

Explanation

A nurse is planning to run a group for clients diagnosed with paranoia and schizophrenia on an acute care mental health unit. Which of the following actions should the nurse plan to take to create a therapeutic environment?

Correct Answer is C

Explanation

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