A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

"What coping methods help you when you feel bad?"

"Do you have thoughts of suicide?"

"Tell me why you hurt yourself."

"Who can we call to support you?"

Answer and Explanation

The Correct Answer is B

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.

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

Explanation

Rationale:

A. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift risks forgetting important details and compromises accuracy. Best practice is to document interventions and observations as close to the time of care as possible to ensure timely, complete records.

B. Delegate collection of vital signs to the assistive personnel on the team: Delegating routine tasks like vital sign collection allows the nurse to focus on complex responsibilities requiring clinical judgment. This supports time efficiency while ensuring client care needs are still met promptly.

C. Make a priority to-do list at the beginning of the shift: Creating a task list based on client acuity and scheduled interventions helps the nurse remain focused and organized. Prioritizing tasks early supports decision-making and improves workflow throughout the shift.

D. Keep track of how long it takes to complete certain tasks: Monitoring time spent on different tasks helps identify inefficiencies and allows the nurse to adjust workflow. This self-awareness supports better time management in future shifts.

E. Complete activities with one client before moving to another client: Focusing on one client at a time may lead to inefficiencies and delayed care for other clients. Nurses should cluster care and prioritize based on client needs, rather than adhering rigidly to completing all care for one client before moving on.

A. Oxytocin B. Misoprostol C. Magnesium sulfate D. Indomethacin

Correct Answer is C

Explanation

Rationale:

A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.

B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.

C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.

D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.

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A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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