A client in the community is experiencing an emotional crisis after her family was killed in a house fire. The client states, "I can't take it anymore." To provide safe care, which of the following actions would the nurse take first?
a. Recommend hospitalization.
b. Provide emotional support.
c. Conduct a suicide assessment.
d. Provide reassurance of access to care.
C
The client's comment should alert the nurse to conduct a suicide assessment. The nurse must determine if the client is experiencing feelings of severe despair that could lead to self-destructive or suicidal behavior. This assessment would begin with questioning the client about thoughts of self-harm.
You might also like to view...
Which of the following patients is most likely to benefit from the administration of an adrenergic agonist?
A) A man who is in cardiogenic shock following a myocardial infarction B) A man who has a diagnosis of primary hypertension C) A woman who has been admitted with a suspected ischemic stroke D) A woman who is in labor and may require a caesarean section
The client is undergoing progressive ambulation on the third day after a myocardial infarc-tion. Which clinical manifestation would indicate to the nurse that the client should not yet be advanced to the next level?
A. Facial flushing B. Onset of chest pain C. Heart rate increase of 10 beats/min at completion of ambulation D. Systolic blood pressure increase of 10 mm Hg at completion of ambulation
Closure of the ductus arteriosus usually occurs:
a. 24 to 48 hours after birth. b. after 7 days of life. c. between the second and third month. d. during the toddler period.
A patient asks the nurse, "What is blood pressure?" The nurse would most appropriately respond:
1. "A measurement that should always be 120/80 unless complications are present." 2. "The amount of pressure exerted on your veins by the blood." 3. "A measurement that takes into consideration the amount of blood that your heart is pumping and the size of the vessel diameter the heart must pump against." 4. "A complex measurement that should only be discussed with your health care provider."