Which nursing interventions will be implemented for a patient who ...

[mynx]

Which nursing interventions will be implemented for a patient who is actively suicidal? Select all that apply.
 
  a. Maintain arm's-length, one-on-one direct observation at all times.
  b. Check all items brought by visitors and remove risk items.
  c. Use plastic eating utensils; count utensils upon collection.
  d. Remove the patient's eyeglasses to prevent self-injury.
  e. Interact with the patient every 15 minutes.

Question 2

A college student is extremely upset after failing two examinations. The student said, No one understands how this will hurt my chances of getting into medical school.
 
  The student then suspends access to his social networking website and turns off his cell phone. Which suicide risk factors are evident? Select all that apply.
 
  a. Shame
  b. Panic attack
  c. Humiliation
  d. Self-imposed isolation
  e. Recent stressful life event

[sarajane1989]

Answer to Question 1

ANS: A, B, C
One-on-one observation is necessary for anyone who has limited or unreliable control over suicidal impulses. Finger foods allow the patient to eat without silverware; no silver or glassware orders restrict access to a potential means of self-harm. Every-15-minute checks are inadequate to assure the safety of an actively suicidal person. Placement in a public area is not a substitute for arm's-length direct observation; some patients will attempt suicide even when others are nearby. Vision impairment requires eyeglasses (or contacts); although they could be used dangerously, watching the patient from arm's length at all times would allow enough time to interrupt such an attempt and would prevent the disorientation and isolation that uncorrected visual impairment could create.

Answer to Question 2

ANS: A, C, D, E
Failing examinations in the academic major constitutes a recent stressful life event. Shame and humiliation related to the failure can be hypothesized. The statement, No one can understand, can be seen as recent lack of social support. Terminating access to one's social networking site and turning off the cell phone represents self-imposed isolation. The scenario does not provide evidence of panic attack.

[mynx]

Gracias!

[strudel15]

TYSM