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A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
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A nurse is providing a community health education class about suicide prevention. Which of the following should the nurse identify as risk factors for suicide? (Select all that apply.)
- A. Substance use disorder
- B. Age greater than 45 years old
- C. Female gender
- D. Currently married
- E. Schizophrenia
Correct Answer: A, B, E
Rationale: The correct answers are A, B, and E. Substance use disorder is a known risk factor for suicide as it can lead to increased impulsivity and impaired decision-making. Age greater than 45 years old is a risk factor due to factors such as isolation, health issues, and life changes. Schizophrenia is associated with a higher risk of suicide due to the symptoms of the disorder and the impact on one's mental well-being. Choices C and D are incorrect as being female or currently married are not universal risk factors for suicide. The absence of choices F and G also indicates that they are not relevant risk factors for suicide.
A nurse is assessing a client who has a mood disorder to determine his readiness for discharge. Which of the following statements by the client indicates he is ready for discharge?
- A. "Right now, I can't bathe or dress myself, but that's not important."
- B. "When I get home, I'm going to let the people who put me here know how angry I am."
- C. "I will take my medicines as I should and know to call the number you gave me if I have bad thoughts."
- D. "Taking care of myself is important, but it's okay if I want to take a break and not do anything."
Correct Answer: C
Rationale: Adherence to medication and awareness of emergency contacts indicate readiness for discharge.
A client who has bipolar disorder approaches the nurse and reveals fresh, self-inflicted, superficial cuts going up and down his right arm. Which of the following actions should the nurse take first?
- A. Implement the client's behavioral modification plan.
- B. Document the size and location of the cuts.
- C. Assess the client's intent and suicide risk.
- D. Administer a tetanus antitoxin.
Correct Answer: C
Rationale: The correct answer is C: Assess the client's intent and suicide risk. This is the first action the nurse should take to ensure the immediate safety of the client. By assessing the client's intent and suicide risk, the nurse can determine the severity of the situation and the appropriate level of intervention needed. This assessment will guide the nurse in developing a safety plan to prevent further self-harm or potential suicide attempts.
Choice A is incorrect because implementing the client's behavioral modification plan is not the priority when the client is actively engaging in self-harm behavior.
Choice B is incorrect as documenting the size and location of the cuts can be done after ensuring the client's immediate safety.
Choice D is incorrect as administering a tetanus antitoxin is not the priority in this situation and does not address the client's emotional and psychological needs.
In summary, assessing the client's intent and suicide risk is the most critical step to ensure the client's safety and well-being in a situation involving self-h
A newly admitted client with obsessive-compulsive disorder (OCD) is performing ritualistic behaviors. What should the nurse do first?
- A. Discuss alternative coping strategies
- B. Identify precipitating factors for rituals
- C. Instruct on relaxation techniques
- D. Provide a structured activity schedule
Correct Answer: B
Rationale: The correct answer is B: Identify precipitating factors for rituals. This is the first step because understanding what triggers the client's rituals is crucial in developing an effective treatment plan. By identifying these factors, the nurse can address the root cause of the behavior and work towards reducing or eliminating it. Discussing coping strategies (A) may come later once the triggers are identified. Instructing on relaxation techniques (C) and providing a structured activity schedule (D) are helpful interventions but addressing the triggers takes precedence.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.