Examkin

Question

Difficulty: MediumMental Health Concepts

A middle-aged adult is recovering from a bowel resection on a surgical floor. The client has a secondary diagnosis of major depressive disorder. When the practical nurse (PN) enters the room with morning medications, the client turns away and mutters, "There is no point in taking those anymore. Everyone would be better off without me here." Which actions should the PN take? Select all that apply.

  1. Stay at the bedside to maintain constant visual observation of the client.Answer
  2. Clear the immediate environment of sharp objects, unnecessary cords, and extra trash liners.Answer
  3. Inquire whether the client has formulated a specific plan to end their life.Answer
  4. D
    Encourage the client by stating, "Things will look brighter once you are fully healed from the surgery."
  5. E
    Secure the client's arms to the bedframe using soft limb holders to prevent potential self-harm.
  6. F
    Inform the charge nurse that the PN will independently complete the comprehensive suicide risk assessment.

Answer

The correct actions are to stay at the bedside to maintain constant visual observation, clear the immediate environment of hazards, and directly ask if the client has a specific plan for self-harm.
The client's statements strongly suggest a high risk for suicide. Immediate nursing priorities involve establishing and maintaining a safe environment. This includes staying with the client to prevent isolation, removing any objects from the room that could be used for self-injury, and directly questioning the client about the presence of a specific suicide plan to gather critical safety data for the RN.

Step-by-Step Solution

1
Analyze the client's statement for underlying themes and potential risks.
The statement indicates profound hopelessness and passive or active suicidal ideation.
Recognizing acute safety risks is the foundational step in prioritizing nursing interventions in any clinical setting.
2
Identify the immediate safety and environmental interventions required.
The PN must secure the environment by removing dangerous items and ensure the client is not left alone.
The client's immediate physical safety takes absolute precedence over routine tasks such as medication administration.
3
Determine the appropriate scope of practice for the PN regarding data collection.
The PN must directly collect specific data regarding the client's immediate intent to self-harm and promptly escalate findings to the RN.
While comprehensive psychological assessment belongs to the RN, asking direct safety questions and reporting findings falls within the expected PN role.

Key Concept

Implementing suicide precautions and therapeutic communication within the Practical Nurse scope of practice.
Rate this question

Topics

Mental Health Concepts

More questions from this topic