After threatening to jump off of a bridge, a client is brought to ...

[Pineappleeh]

After threatening to jump off of a bridge, a client is brought to an emergency department by police. To assess for suicide potential, which question should a nurse ask first?
 
  1. Are you currently thinking about harming yourself?
  2. Why do you want to harm yourself?
  3. Have you thought about the consequences of your actions?
  4. Who is your emergency contact person?

Question 2

A high school student has learned that she cannot graduate. Her boyfriend will be attending a college out of state that she planned to attend. She is admitted to a psychiatric unit after overdosing on Tylenol.
 
  Which is the priority nursing diagnosis for this client? 1. Ineffective coping R/T situational crisis AEB powerlessness
  2. Anxiety R/T fear of failure
  3. Risk for self-directed violence R/T hopelessness
  4. Risk for low self-esteem R/T loss events AEB suicidal ideations

[tofugiraffe]

Answer to Question 1

1
Rationale: The nurse should first assess the client for current harmful or suicidal thoughts to minimize risk of harm to the client and provide appropriate interventions. A suicidal client is experiencing a psychiatric emergency in which the crisis team should assess for client safety as a priority.

Answer to Question 2

3
Rationale: The priority nursing diagnosis for this client is risk for self-directed violence R/T hopelessness. Nurses should prioritize diagnoses and outcomes based on potential safety risk to the client or others.

[Pineappleeh]

Thanks for the timely response, appreciate it

[xiazhe]

Gracias!