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Zorluk: KolayCrisis Intervention

A nurse is caring for a client who was admitted to the psychiatric unit following a severe situational crisis and a subsequent suicide attempt. For the first few days, the client was profoundly depressed, tearful, and withdrawn. Today, the client suddenly appears remarkably peaceful, is smiling, and begins giving away prized personal belongings to other clients on the unit. Which action is the nurse's priority?

  1. A
    Document the client's change in behavior as a positive response to crisis intervention therapies.
  2. B
    Contact the interdisciplinary team to recommend initiating the discharge planning process.
  3. Immediately assess the client for suicidal ideation and the presence of a specific suicide plan.Cevap
  4. D
    Praise the client for their generosity and encourage continued interaction with peers.

Cevap

The nurse's priority is to immediately assess the client for suicidal ideation and the presence of a specific suicide plan.
When a client in a crisis who has been severely depressed suddenly appears peaceful and begins giving away personal items, it is a significant warning sign. This behavioral shift frequently indicates the client has made a finalized plan to commit suicide and is experiencing relief from making the decision. The nurse's absolute priority is client safety, requiring an immediate, direct assessment of suicidal intent.

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1
Analyze the client's clinical presentation and recent history.
The client has a recent suicide attempt and transitioned suddenly from severe depression to a peaceful, giving state.
Identifying acute behavioral changes is critical in determining the client's current status and risk level.
2
Correlate the behavioral change with psychiatric risk factors.
A sudden lifting of depression and giving away prized possessions are strong indicators that the client has finalized a suicide plan and feels relief.
These classic red flags require immediate recognition to prevent self-harm.
3
Determine the highest priority nursing intervention.
The priority action is to ensure client safety by directly assessing for suicidal intent and a specific plan.
According to Maslow's hierarchy and basic safety principles, preserving the client's life is always the primary concern.

Anahtar Kavram

Recognizing signs of imminent suicide risk, including sudden mood improvement and giving away belongings, is critical for client safety during crisis intervention.
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Crisis Intervention

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