A nurse is assigned to care for several clients on a mental health unit. One of the clients who has suicidal ideation starts to verbalize clear intent to self harm. Which of the following actions should the nurse take?

Request the client’s caregivers to remain with the client.

Notify the supervisor that the client requires one to one nursing observation

Assign the client to, a private room.

Increase the frequency of client assessment to hourly.

Answer and Explanation

The Correct Answer is B

A) "Request the client’s caregivers to remain with the client.": While having caregivers present can provide some emotional support, this is not a sufficient or appropriate intervention when a client is actively expressing intent to self-harm. Caregivers may not be trained to recognize subtle changes in the client’s condition, and they might not be able to provide the level of safety required. It is essential that a trained nurse or professional provides direct observation.

B) "Notify the supervisor that the client requires one-to-one nursing observation.": This is the most appropriate and immediate action when a client verbalizes a clear intent to self-harm. One-to-one nursing observation ensures that the client is under constant surveillance, which is crucial for preventing harm and providing immediate intervention if the client attempts to act on their suicidal thoughts.

C) "Assign the client to a private room.": Assigning the client to a private room is not a recommended action when the client is expressing intent to self-harm. In fact, isolation in a private room could increase the risk of harm. The priority is to ensure the client is closely monitored, and being placed in a private room may reduce the ability for staff to observe and intervene as needed.

D) "Increase the frequency of client assessment to hourly.": While increasing the frequency of assessments is important, it is not sufficient to prevent self-harm in a client who is at immediate risk. The client needs continuous observation to ensure their safety. One-to-one nursing observation is more effective than periodic assessments for clients with active suicidal ideation or intent.

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Correct Answer is D

Explanation

A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.

B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.

C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.

D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.

A. "Draw up the insulin lispro and insulin glargine in separate syringes. B. "Take an extra dose of insulin lispro prior to aerobic exercise." C. ‘’Expect insulin glargine to be cloudy." D. "Anticipate that the insulin glargine will peak in 3 hours."

Correct Answer is A

Explanation

A) "Draw up the insulin lispro and insulin glargine in separate syringes.":
Insulin lispro (a rapid-acting insulin) and insulin glargine (a long-acting insulin) should be administered separately, as they have different properties and mechanisms of action. Mixing them in one syringe can affect their effectiveness and may cause inaccurate dosing. Therefore, the nurse should instruct the client to draw up each insulin in a separate syringe to ensure proper administration and action of both insulins.

B) "Take an extra dose of insulin lispro prior to aerobic exercise.":
Taking an extra dose of insulin lispro before exercise is not recommended unless directed by a healthcare provider. Exercise can lower blood glucose levels, and additional insulin may increase the risk of hypoglycemia. Instead, clients with diabetes are typically advised to monitor their blood glucose levels before and after exercise and adjust their insulin dose or carbohydrate intake accordingly, under the guidance of their healthcare provider.

C) "Expect insulin glargine to be cloudy.":
Insulin glargine is a clear, long-acting insulin. It should not be cloudy. If the insulin appears cloudy, it may be a sign that the insulin has been improperly stored or is no longer effective. The nurse should educate the client to inspect the insulin for cloudiness or particles and to discard any insulin that appears abnormal.

D) "Anticipate that the insulin glargine will peak in 3 hours.":
Insulin glargine is a long-acting insulin that does not have a pronounced peak. It provides a steady release of insulin over 24 hours and helps to maintain baseline insulin levels. It is not meant to peak like rapid-acting or short-acting insulins. Therefore, this instruction is incorrect, as insulin glargine does not follow the same peak-action pattern as other insulins.

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A nurse is assigned to care for several clients on a mental health unit. One of the clients who has suicidal ideation starts to verbalize clear intent to self harm. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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