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 D

Explanation

Choice A rationale:

Drinking green tea does not directly cause lithium toxicity.

Choice B rationale:

Moderate exercise does not directly cause lithium toxicity.

Choice C rationale:

Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.

Choice D rationale:

Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.

A. "Why do you feel like you will never get better? Do you not have confidence in the medical team?". B. "We will work with you to help you develop ways to manage your symptoms that are caused by the disorder.”. C. "Let's focus on the physical symptoms that you have.”. D. "Although there isn't a cure for this disorder, I am sure you will feel better someday.”.

Correct Answer is B

Explanation

Choice A rationale:

Asking why the client feels they will never get better might come across as dismissive or confrontational.

Choice B rationale:

This response acknowledges the client’s feelings and offers a supportive approach to managing the symptoms of somatic symptom disorder. This disorder is characterized by a significant focus on physical symptoms that cause major distress and/or problems functioning. The main treatment is psychotherapy, and medication might be given in some cases.

Choice C rationale:

Focusing only on the physical symptoms might not address the emotional distress that the client is experiencing.

Choice D rationale:

While it’s important to offer hope, this response might come across as dismissive of the client’s current feelings.

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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

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

Correct Answer is D

Explanation

A nurse is caring for a client who was recently diagnosed with somatic symptom disorder. The client says to the nurse, "I don't understand, they can't find anything medically wrong with me. I guess I will never feel better.”. Which of the following responses is the most therapeutic?

Correct Answer is B

Explanation

A nurse is caring for a client in an outpatient clinic. Exhibits The nurse should identify which of the following findings as manifestations of somatic symptom disorder? (Select all that apply.).

A nurse is educating a client who is prescribed clozapine. Which of the following findings should the nurse identify as consistent with agranulocytosis and instruct the client to monitor?

A nurse is assessing a client who has schizophrenia which has been treated with fluphenazine for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?.

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?.

A nurse is teaching a client who has a new prescription for lithium to treat bipolar disorder. The nurse should instruct the client to ensure an adequate intake of which of the following dietary elements?

Which nursing intervention will have the greatest impact on both the management of care and on milieu environment when considering the clients diagnosed with bipolar disorder?

A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?

A nurse is assessing a client who has schizophrenia and is taking risperidone. Which of the following findings should the nurse expect?.

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?.