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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:
Using bargaining to improve behavior is not recommended for individuals with Antisocial Personality Disorder. It can reinforce manipulative behaviors.
Choice B rationale:
Providing rewards for positive behavior can be beneficial. It can encourage the development of healthier behaviors.
Choice C rationale:
Ignoring negative behavior is not recommended. It’s important to address these behaviors directly and establish clear consequences.
Choice D rationale:
Maintaining a low-stimuli environment can be beneficial for individuals with Antisocial Personality Disorder. It can help reduce agitation and aggressive behaviors.

A. Sexual dysfunction. B. Muscle spasms of the neck. C. Tremors of the hands. D. Fidgeting behavior. E. Blurred vision.

Correct Answer is ["B","C","D"]

Explanation

Choice A rationale:
Sexual dysfunction is not typically associated with extrapyramidal side effects (EPS). EPS are usually characterized by involuntary motor symptoms.
Choice B rationale:
Muscle spasms of the neck, also known as dystonia, are a common symptom of EPS12.
Choice C rationale:
Tremors of the hands can be a sign of EPS, often associated with drug-induced parkinsonism.
Choice D rationale:
Fidgeting behavior, or akathisia, is a common symptom of EPS. It is characterized by a feeling of restlessness and an inability to sit still.
Choice E rationale:
Blurred vision is not typically associated with EPS. It is more likely to be a side effect of the medication itself, not a symptom of EPS12.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing for the presence of extrapyramidal side effects (EPS) in a client who is taking chlorpromazine. Which of the following findings should the nurse recognize as EPS? (Select all that apply.).

Correct Answer is ["B","C","D"]

Explanation

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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?.