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

Explanation

Rationale:

A. The client needs strict measurement of intake and output: This task can be delegated to assistive personnel as it involves routine data collection without complex clinical judgment.

B. The client develops a postoperative fever: A postoperative fever may indicate infection or other complications requiring assessment, clinical judgment, and intervention by a registered nurse.

C. The client is experiencing a therapeutic effect from their treatment: Monitoring expected therapeutic effects is routine and can often be overseen by licensed practical nurses or assistive personnel, depending on policy.

D. The client needs routine wound care performed: Routine wound care is generally a delegated nursing task that does not require the advanced assessment or clinical decision-making of an RN unless complications arise.

A. Prescribed epoetin V B. Sleeps 8 to 10 hr per night C. Uses a firm-bristled toothbrush D. Prescribed vitamin B IM

Correct Answer is C

Explanation

Rationale:

A. Prescribed epoetin V: Epoetin is used to stimulate red blood cell production, typically for anemia related to chronic kidney disease or chemotherapy. It is not a standard treatment for pernicious anemia and does not directly increase the client’s injury risk in this context.

B. Sleeps 8 to 10 hr per night: Sleeping 8 to 10 hours is within the normal range for many adults, particularly those recovering from fatigue associated with anemia. This finding does not pose any additional risk for injury.

C. Uses a firm-bristled toothbrush: A firm-bristled toothbrush can cause gum irritation or bleeding, especially in clients with anemia who may have fragile oral mucosa or concurrent thrombocytopenia. This increases the risk of oral injury or infection and should be avoided.

D. Prescribed vitamin B IM: Vitamin B12 IM injections are the standard treatment for pernicious anemia due to impaired intrinsic factor and poor absorption. This intervention helps correct the deficiency and prevent neurologic complications, not increase injury risk.

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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

Explanation

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