Level: Foundational
Difficulty: Easy
Subtopic: Suicide risk
NCLEX: A 42-year-old client in a crisis stabilization unit is being evaluated for expressions of hopelessness. Assessmen…
Psychiatric / mental health nursing Psychosocial Integrity
Case Study
A 42-year-old client in a crisis stabilization unit is being evaluated for expressions of hopelessness. Assessment data include the client states, "I don't want to live anymore" and has a plan with access to means. Which intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
B. Delay teaching until the day of discharge only.
C. Ignore small changes until they become severe.
D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale
Correct answer: D. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.