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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Dilated pupils: Hydromorphone, an opioid, typically causes pupil constriction (miosis), not dilation. Dilated pupils may occur in opioid overdose only as a sign of severe hypoxia, but are not a common adverse effect of appropriate therapeutic dosing.
B. Urinary retention: Urinary retention is a known adverse effect of opioids like hydromorphone. Opioids can impair bladder muscle tone and suppress the urge to void by affecting central and peripheral nervous system pathways.
C. Hypertension: Hydromorphone generally causes hypotension due to vasodilation and histamine release. Hypertension is not a typical response and would more likely suggest untreated pain or another underlying condition.
D. Tachypnea: Opioids depress the respiratory center in the brain, which can lead to bradypnea rather than tachypnea. An increase in respiratory rate is not characteristic of opioid use unless it’s a response to severe, unmanaged pain.
Correct Answer is B
Explanation
Rationale:
A. "I will position my arms away from my body when pushing an object.": Keeping the arms close to the body provides better leverage and reduces strain on the muscles and joints. Extending arms away increases risk of injury.
B. "I will position my body to face an object, so I avoid twisting: Facing the object directly helps maintain proper spinal alignment and reduces the risk of back injury by minimizing twisting motions during lifting or pushing.
C. "I will position my legs close together before lifting.": Keeping legs close together decreases stability and increases risk of losing balance. A wider stance improves balance and distributes weight evenly during lifting.
D. "I will position objects away from my body before lifting them.": Objects should be held close to the body to reduce strain on the back and arms. Holding objects away increases lever arm forces and injury risk.
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