ATI Mental Health 1 Flashcards
A nurse is planning care for a client who has thoughts of suicide. Which of the following goes to the nurse include in the client’s plan of care?
A) The client will identify positive aspects of others.
B) The client agrees to notify a staff member of thoughts of self-harm.
C) The client will engage in an independent diversional activity.
D) The client will not verbalize thoughts or feelings related to suicide.
B) The client agrees to notify a staff member of thoughts of self-harm.
The nurse should instruct the client to notify staff if he has suicidal thoughts so that the client’s needs are immediately addressed and actions are taken to prevent self-injury or suicide.
A) The nurse should assist the client to identify positive aspects about himself to improve the client’s sense of self-worth.
C) The nurse should encourage the client to participate in activities with others to decrease the client’s sense of isolation.
A nurse enters a client’s room and observes that the client is agitated and pacing rapidly. The client looks at the nurse and says, “ Back off. Leave me alone.” Which of the following statements should the nurse make?
A) “I demand that you calm down now. Your behavior is unacceptable.”
B) “I will close the door to provide privacy, and you can tell me what is bothering you.”
C) “I will give you space if you calm down. Tell me what is causing you to feel so tense.”
D) “I will leave you alone for a few minutes while you try to control yourself.”
C) “I will give you space if you calm down. Tell me what is causing you to feel so tense.”
The nurse should stay at a safe distance and remain calm while stressing the importance of maintaining control. The nurse should use verbal de-escalation techniques while determining the client’s needs and respecting the client’s personal space.
B) The nurse should consider staff safety when attempting to calm the client. By closing the door, the nurse does not have an escape route should the client become violent.
D) The nurse should avoid leaving the client alone while he is in an agitated state and a potential danger to himself. If other de-escalation techniques are ineffective, then the nurse might implement seclusion in a safe and monitored environment.
