Alzheimer’s Delirium and Dementia Q 11
A 48-year-old male client is brought to the psychiatric emergency room after attempting to jump off a bridge. The client’s wife states that he lost his job several months ago and has been unable to find another job. The primary nursing intervention at this time would be to assess for:
A. A past history of depression.
B. Current plans to commit suicide.
C. The presence of marital difficulties.
D. Feelings of excessive failure.
Correct Answer: B. Current plans to commit suicide
Whether there is a suicide plan is a criterion when assessing the client’s determination to make another attempt. Keep accurate and thorough records of client’s behaviors (verbal and physical) and all nursing/physician actions. Put on either suicide precaution (one-on-one monitoring at one arm’s length away) or suicide observation (15-minute visual check of mood, behavior, and verbatim statements), depending on level of suicide potential. Protection and preservation of the client’s life at all costs during crisis is part of medical and nursing staff’s responsibility. Follow unit protocol.
Option A: Keep accurate and timely records, document client’s activity, usually every 15 minutes (what client is doing, with whom, and so on). Follow unit protocol. Accurate documentation is vital. The chart is a legal document as to the client’s “ongoing status,” intervention taken, and by whom.
Option C: Encourage the client to talk about their feelings and problem solving alternatives. Talking about feelings and looking at alternatives can minimize suicidal acting out. Encourage the client to talk freely about feelings and help plan alternative ways of handling disappointment, anger, and frustration. Gives the client other ways of dealing with strong emotions and gaining a sense of control over their lives.
Option D: Encourage the client to avoid decisions during the time of crisis until alternatives can be considered. During crisis situations, people are unable to think clearly or evaluate their options readily. Construct a no-suicide contract between the suicidal client and nurse. Use clear, simple language. When the contract is up, it is renegotiated (If this is accepted procedure at your institution). The no-suicide contract helps client know what to do when they begin to feel overwhelmed by pain (e.g., “I will speak to my nurse/counselor/support group/family member when I first begin to feel the need to end my life”).