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 C

Explanation

A. Facial erythema is not a primary diagnostic feature of this specific respiratory bacterial infection. While intense coughing fits may cause temporary facial flushing or venous congestion, it is not a hallmark finding. Conditions like fifth disease or slapped-cheek syndrome are more likely to present with persistent malar rashes. This sign lacks the specificity required for a pertussis diagnosis.

B. Peeling of the skin on the extremities, known as desquamation, is classically associated with Kawasaki disease or scarlet fever. Bordetella pertussis does not typically produce the exotoxin profile necessary to cause significant integumentary shedding or widespread dermatological involvement. The pathology of pertussis is primarily localized to the ciliated epithelium of the respiratory tract. It is not an exfoliative disease.

C. In the catarrhal phase of the infection, a low-grade temperature is a standard clinical finding as the immune system responds to the initial bacterial colonization. The presence of systemic inflammation results in mild pyrexia alongside coryza. This manifestation is most prominent before the onset of the characteristic paroxysmal cough. Fever helps differentiate early pertussis from non-inflammatory conditions.

D. A beefy, red tongue, often described as a strawberry tongue, is a classic sign of scarlet fever or toxic shock syndrome. This manifestation occurs due to capillary permeability and inflammation of the lingual papillae caused by Streptococcus pyogenes. Pertussis involves the respiratory mucosa rather than the oral structures or the tongue. This symptom indicates a different bacterial or inflammatory etiology.

A. Sit in a hot tub for 30 min every evening B. Raise chairs to keep knees lower than hips C. Perform pelvic rocking exercises several times per day D. Use the arms to pick up heavy items.

Correct Answer is C

Explanation

A) Sit in a hot tub for 30 min every evening:
While a warm bath or hot tub may provide temporary relief for some types of pain, it is not generally recommended during pregnancy, especially in the later stages, because prolonged exposure to hot water can raise the body's core temperature. This could pose a risk to both the mother and fetus, especially at 34 weeks of gestation. It is safer to use warm compresses or baths for shorter durations.

B) Raise chairs to keep knees lower than hips:
This recommendation is incorrect. For relieving lower back pain, it is better for the knees to be slightly higher than the hips when sitting. This posture helps to alleviate strain on the lower back by reducing pressure on the spine. Sitting with the knees lower than the hips can actually exacerbate lower back pain.

C) Perform pelvic rocking exercises several times per day:
Pelvic rocking exercises are an excellent recommendation for relieving lower back pain during pregnancy. These exercises involve gently rocking the pelvis forward and backward, which can help to strengthen the lower back muscles, relieve tension, and improve posture. They are specifically beneficial in alleviating discomfort during pregnancy, particularly at 34 weeks of gestation.

D) Use the arms to pick up heavy items:
While using the arms instead of the back is generally a good practice for avoiding strain, this advice does not directly address the specific issue of lower back pain during pregnancy. Pregnant clients should be advised to avoid lifting heavy objects whenever possible, as the added weight can exacerbate back pain. Safe body mechanics, such as squatting down to pick up objects and using leg muscles rather than back muscles, are also important.

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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?

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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