A severely depressed client's risk for self-directed violence ...

[cherise1989]

A severely depressed client's risk for self-directed violence increases when:
 
  1. A no-suicide contract is made with the client.
  2. The client is encouraged to discuss feelings.
  3. The client is asked to discuss the suicide plan.
  4. The antidepressant medication begins to work.

Question 2

A client comes to the clinic complaining of headaches. Further assessment reveals three one-inch bald spots at different locations on the client's scalp. The client states the headache and the bald spots resulted from an accident.
 
  The client's partner, who has accompanied the client into the exam room, often finishes the client's sentences. The nurse should:
  1. Ask the partner to remain in the waiting room while the client is examined.
  2. Alert hospital security about the potential for violence.
  3. Encourage the partner to remain with the client to provide information about the client's health.
  4. Contact the local authorities.

[pikon]

Answer to Question 1

4
Rationale: When the antidepressant medication begins to work, the depression begins to lift and the client may have the energy to follow through with self-directed violence. Asking to discuss the suicide plan and encouraging the client to discuss feelings convey care and concern and do not increase the risk of self-directed violence. A no-suicide contract conveys to the client that the staff members want to maintain client safety.

Answer to Question 2

1
Rationale: An implausible explanation for a client's injuries and a partner's pattern of finishing the client's sentences should arouse the nurse's suspicion that the client may be the victim of spousal abuse. Asking the partner to remain in the waiting room allows the client to speak more freely. The nurse should assure the client that privacy is maintained so the client can talk about what has really occurred. Additional assessment needs to be done prior to involving the authorities. Usually abusers do not act out in the presence of others, so alerting hospital security may be unnecessary.

[cherise1989]

TYSM

[phuda]

Excellent