A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

"I just feel like my life is filled with emptiness."

"I have three firearms locked in a safe at home."

"My daughter is the only reason I keep trying."

"My panic attacks happen once every month."

Answer and Explanation

The Correct Answer is B

Choice A rationale:
This statement expresses the client's emotional state but does not provide information about immediate access to lethal means.

Choice B rationale:
This comment is the most crucial to document because it indicates the client's access to potentially lethal means, which is a significant risk factor for committing suicide.

Choice C rationale:
This statement provides information about a source of support in the client's life but does not indicate immediate access to lethal methods.

Choice D rationale:
This statement provides information about the frequency of panic attacks but does not indicate immediate access to lethal means.

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Correct Answer is B

Explanation

Choice A rationale:
Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation.

Choice B rationale:
Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gentle, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area. Antibacterial soap may be too harsh and could lead to skin irritation.

Choice C rationale:
Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritation.

Choice D rationale:
Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage.

A. Provide a supportive, structured environment for meals. B. Assess weight, vital signs, potassium, and other electrolytes. C. Discuss alternative strategies for binging and purging. D. Monitor the client after meals for possible vomiting.

Correct Answer is B

Explanation

Choice A rationale:
Providing a supportive, structured environment for meals is an important aspect of the overall care plan for individuals with bulimia. However, it should not be the first intervention when a client is admitted with potential physical complications. Addressing the client's physical condition and safety is the initial priority.

Choice B rationale:
This is the correct initial intervention. Bulimia can lead to severe medical complications, including electrolyte imbalances, which can be life-threatening. Assessing the client's weight, vital signs, and electrolyte levels is crucial to determine the severity of physical issues and guide appropriate medical interventions.

Choice C rationale:
Discussing alternative strategies for binging and purging is an important aspect of treatment for bulimia, but it should follow the initial assessment of the client's physical condition. Addressing the client's medical needs takes precedence over discussing alternatives.

Choice D rationale:
While monitoring the client for possible vomiting is important in the care of individuals with bulimia, it should not be the first intervention when the client is admitted. Assessing the client's physical status and addressing potential medical complications should come before monitoring for specific behaviors.

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A client is admitted to the hospital with suicidal ideation. When completing the health history and admission assessment interview, which client comment is most important for the nurse to document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Correct Answer is B

Explanation

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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