Which of the following interventions should be prioritized in the care of the suicidal client?
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Solution
Remove all potentially harmful items from the client’s room.
Accessibility of the means of suicide increases the lethality. Allowing patient to express feelings and setting a no-suicide contract are interventions for a suicidal client but blocking the means of suicide is a priority.
Option C: Increasing self-esteem is an intervention for depressed clients bur not specifically for suicide.
The client says to the nurse “Pray for me” and entrusts her wedding ring to the nurse. The nurse knows that this may signal which of the following:
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Solution
Suicidal ideation
The client’s statement is a verbal cue of suicidal ideation, not anxiety. While suicide is common among clients with major depression, this occurs when their depression starts to lift. Hopelessness indicates no alternatives available and may lead to suicide, the statement and nonverbal cue of the client indicate suicide.
One morning the nurse sees the client in a depressed mood. The nurse asks her “What are you thinking about?” This communication technique is:
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Solution
Giving broad opening
Broad opening technique allows the client to take the initiative in introducing the topic.
Options A, B, and C are all therapeutic techniques but these are not exemplified by the nurse’s statement.
The nurse’s therapeutic response is:
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Solution
”It must really be frustrating for you. How can I best help you?”
This response reflects the pain due to loss. A helping relationship can be forged by showing empathy and concern.
Option A: This is not therapeutic since it passes the buck or responsibility to the clergy.
Option B: This response is not therapeutic because it gives the client the impression that she is right which prevents the client from reconsidering her thoughts.
Option C: This statement passes judgment on the client.
Situation: A widow age 28, whose husband died one (1) year ago due to AIDS, has just been told that she has AIDS. Panky says to the nurse, “Why me? How could God do this to me?” This reaction is one of:
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Solution
Anger
Anger is experienced as reality sets in. This may either be directed to God, the deceased or displaced on others.
Option A: Depression is a painful stage where the individual mourns for what was lost.
Option B: Denial is the first stage of the grieving process evidenced by the statement “No, it can’t be true.” The individual does not acknowledge that the loss has occurred to protect self from the psychological pain of the loss.
Option D: In bargaining the individual holds out hope for additional alternatives to forestall the loss, evidenced by the statement “If only…”
A client on Lithium has diarrhea and vomiting. What should the nurse do first:
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Solution
Hold the next dose and obtain an order for a stat serum lithium level
Diarrhea and vomiting are manifestations of Lithium toxicity. The next dose of lithium should be withheld, and a test is done to validate the observation.
Option A: The manifestations are not due to drug interaction.
Option B: Cogentin is used to manage the extrapyramidal symptom side effects of antipsychotics.
Option C: The common side effects of Lithium are fine hand tremors, nausea, polyuria and polydipsia.
The nurse exemplifies an awareness of the rights of a client whose anger is escalating by:
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Solution
Taking a directive role in verbalizing feelings
The client has the right to be free from unnecessary restraints. Verbalization of feelings or “talking down” in a non-threatening environment is helpful to relieve the client’s anger.
Option B: This is a threatening approach.
Options C and D: Seclusion and application restraints are done only when less restrictive measures have failed to contain the client’s anger.
The client is arrogant and manipulative. In ensuring a therapeutic milieu, the nurse does one of the following:
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Solution
Agree on a consistent approach among the staff assigned to the client.
A consistent firm approach is appropriate. This is a therapeutic way of to handle attempts of exploiting the weakness in others or create conflicts among the staff. Bargaining should not be allowed.
Option B: This is not therapeutic because the client tends to control and dominate others.
Option C: Limits are set for interaction time.
Option D: Allowing the client to negotiate, may reinforce a manipulative behavior.
An activity appropriate for the client is:
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Solution
Cleaning
The client’s excess energy can be rechanneled through physical activities that are not competitive like cleaning. This is also a way to dissipate tension.
Option A: Tennis is a competitive activity which can stimulate the client.
Situation: A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talked fast and hyperactive. Initially, the nurse should plan this for a manic client:
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Solution
set realistic limits to the client’s behavior
The manic client is hyperactive and may engage in injurious activities. A quiet environment and consistent and firm limits should be set to ensure safety.
Option B: Clear, concise directions are given because of the distractibility of the client but this is not the priority.
Option C: The manic client tend to externalize hostile feelings, however only non-destructive methods of expression should be allowed
Option D: Nurses set limit as needed. Assigning a staff to be with the client at all times is not realistic.