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:
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.
Correct Answer is B
Explanation
Choice A rationale:
Pseudoparkinsonism is a side effect of antipsychotic medications that mimics the symptoms of Parkinson’s disease, such as tremors and rigidity. It does not typically cause hyperpyrexia or diaphoresis.
Choice B rationale:
Neuroleptic malignant syndrome is a rare but serious side effect of antipsychotic medications. It can cause severe fever (hyperpyrexia), unstable blood pressure, and heavy sweating (diaphoresis)4.
Choice C rationale:
Acute dystonia is a condition of sudden, involuntary muscle contractions. It does not typically cause hyperpyrexia or diaphoresis.
Choice D rationale:
Tardive dyskinesia is a side effect of long-term use of antipsychotic medications, causing involuntary movements, especially around the mouth. It does not typically cause hyperpyrexia or diaphoresis.
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.