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Zorluk: OrtaBehavioral Interventions

A client is admitted to the inpatient psychiatric unit with major depressive disorder and active suicidal ideation. After five days of refusing meals, isolating in their room, and avoiding staff interactions, the client suddenly emerges into the dayroom smiling. The client hands a cherished watch to a peer and states, "The heavy cloud has finally lifted. I know exactly what I have to do now, and everything will be at peace." Which of the following is the priority nursing action?

  1. Maintain direct, continuous one-to-one observation of the client.Cevap
  2. B
    Document the positive behavioral change and transition the client to 15-minute safety checks.
  3. C
    Instruct the unlicensed assistive personnel to perform a standardized suicide risk assessment.
  4. D
    Respond by stating, "I am so glad to see you smiling today and that the treatment is finally working."

Cevap

The correct action is to maintain direct, continuous one-to-one observation of the client to ensure immediate safety.
The client is exhibiting classic red flags for imminent suicide risk: a sudden and unexplained lifting of a severely depressed mood, giving away cherished personal items, and making definitive, cryptic statements about the future. Because the risk of self-harm is critical and immediate, the priority behavioral intervention is to ensure the client is placed on or remains on direct, continuous one-to-one observation by qualified staff.

Adım Adım Çözüm

1
Analyze the client's behavioral changes and statements.
Identify that the sudden mood improvement, giving away possessions, and cryptic statements about peace are high-risk indicators of an organized suicide plan.
When severe depression suddenly lifts, it often means the client has made the decision to die by suicide, providing them with a sense of relief and the energy to carry out the act.
2
Determine the priority nursing intervention based on the assessed risk level.
Select the intervention that provides the highest level of immediate physical safety.
Client safety is the paramount concern in acute psychiatric care. High-risk suicidal behaviors require continuous visual monitoring without delegation to unlicensed staff.

Anahtar Kavram

Recognizing paradoxical mood improvement as an indicator of imminent suicide risk and implementing strict safety measures.
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Konular

Behavioral Interventions

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