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 A

Explanation

Choice A rationale:
Command hallucinations can direct the patient to harm themselves or others, making it the priority to address.
Choice B rationale:
Tactile hallucinations, while distressing, are not typically as immediately dangerous as command hallucinations.
Choice C rationale:
Gustatory hallucinations, while potentially disturbing, do not usually pose an immediate threat.
Choice D rationale:
Visual hallucinations, while potentially distressing, are not typically as immediately dangerous as command hallucinations.

A. GI discomfort and poor coordination. B. Lip smacking and tongue thrusting. C. Blurred vision and jerking motor movements. D. Fever and fluctuating blood pressure.

Correct Answer is A

Explanation

Choice A rationale:

A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.

Choice B rationale:

Lip smacking and tongue thrusting are not typically associated with lithium toxicity.

Choice C rationale:

While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.

Choice D rationale:

Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.

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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?.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is experiencing a variety of hallucinations. Which of the following hallucinations is the priority for the nurse to address?

Correct Answer is A

Explanation

A nurse is reviewing laboratory results for a client and notes a serum lithium level of 1.6 mEq/L. Which of the following manifestations should the nurse expect the client to report?.

Correct Answer is A

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?.