A nurse asks a client who is suicidal to make a safety contract, but the client declines.
Which of the following actions should the nurse identify as the priority?.
Assign a staff member to stay with the client at all times.
Lock the doors to the unit and secure windows so they cannot be opened.
Remove any objects from the client's environment that could be used for self-harm.
Provide the client with plastic eating utensils for meals.
The Correct Answer is A
Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Weight gain is not typically associated with acute mania in bipolar disorder.
Choice B rationale:
Disorganized speech can be a symptom of acute mania, which is characterized by increased energy, feelings of euphoria, racing thoughts, risky behaviors, and an inflated self-image.
Choice C rationale:
While hallucinations can occur in severe bipolar episodes, the client reporting that voices are telling him to write a novel is not specifically indicative of acute mania.
Choice D rationale:
Dressing in all black is not a specific symptom of acute mania.
Correct Answer is D
Explanation
Choice A rationale:
Encouraging family to take the client out of the facility for short periods of time can be beneficial, but it does not address the sudden change in behavior.
Choice B rationale:
Rewarding the client for her change in behavior can reinforce positive behavior, but it does not address the sudden change in behavior.
Choice C rationale:
Asking the client why her behavior has changed can provide insight, but it does not ensure the safety of the client.
Choice D rationale:
Monitoring the client’s whereabouts at all times is important as a sudden change in mood can indicate a higher risk of suicide.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.