A client diagnosed with major depressive episode hears voices commanding self-harm. Which should be the nurse's priority intervention at this time?
1. Obtaining an order for locked seclusion until client is no longer suicidal.
2. Conducting 15-minute checks to ensure safety.
3. Placing the client on one-to-one observation while continuing to monitor suicidal ideations.
4. Encouraging client to express feelings related to suicide.
3
Rationale: The nurse's priority intervention when a depressed client hears voices commanding self-harm is to place the client on one-to-one observation while continuing to monitor suicidal ideations. By providing one-to-one observation, the nurse will be able to interrupt any attempts at suicide.
You might also like to view...
A 75-year-old male is worried that his wartlike dark macules with distinct borders are melanomas. What would be the most likely cause for the macules?
a. Senile lentigo b. Cutaneous papillomas c. Seborrheic keratoses d. Xerosis
A parent states, "I am concerned that my 2-year-old doesn't interact with others while playing in the same space." Which rationale will the nurse use when responding to this parent?
1) Toddler play is parallel. 2) The child is shy and withdrawn. 3) The child may have a learning disability. 4) The child's lack of speech inhibits his or her ability to communicate with other children.
The nurse understands the primary focus of education for a client who has just received a diag-nosis of cancer is to:
1. Introduce self-care measures to support health 2. Discuss the management of treatment-related side effects 3. Reinforce the explanation of the risks of proposed treatments 4. Formulate long-term lifestyle changes to minimize risk factors
An client with terminal cancer is dying. For the past several days, the client has refused food and fluids, and pushes the caregiver's hands away when attempts are made to feed the client or offer any kind of fluid
The family is considering placing a gastrostomy tube because they feel the client is "starving to death." The nurse should: 1. Honor the family's wishes and have them sign a consent form. 2. Talk to the physician so he or she can move forward with the family's wishes. 3. Honor the client's refusal and help the family come to terms with the situation. 4. Take the case to the hospital's ethics committee.