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.
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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Related Questions
Correct Answer is B
Explanation
A) Place the client in Sims' position for catheter insertion: Sims' position (side-lying position) is not typically used for central venous catheter insertion. The client is usually placed in a supine or Trendelenburg position to help facilitate insertion and decrease the risk of air embolism during the procedure.
B) Prepare the client for a chest x-ray to verify catheter placement: After the insertion of a central venous catheter, a chest x-ray is routinely performed to verify the correct placement of the catheter in the superior vena cava or right atrium. This is essential to ensure the catheter is properly positioned and to check for complications like pneumothorax or inadvertent placement in the lung.
C) Use clean technique when changing the catheter dressing: When changing the dressing for a central venous catheter, sterile technique is required, not clean technique. Sterile technique minimizes the risk of infection, which is a major concern when caring for central venous access devices.
D) Verify the amount of TPN solution the client is receiving every 4 hr: While it is important to monitor the amount of TPN being infused and assess for complications, verifying the exact amount every 4 hours is not a standard procedure. Typically, TPN is managed and adjusted by the healthcare provider based on lab results, weight, and clinical status, but constant monitoring of the solution is not required.
Correct Answer is C
Explanation
A) Rubber duck:
A rubber duck may be a suitable toy for a 2-month-old infant during bath time, but it is not considered the most developmentally appropriate for this age. At 2 months, infants are beginning to focus their vision on objects but have limited ability to manipulate toys. Toys such as a rubber duck do not provide the most stimulating developmental experience for an infant at this age.
B) Nesting cups:
Nesting cups are not the most appropriate for a 2-month-old infant. At this stage of development, babies are still in the early stages of hand-eye coordination and grasping skills. Nesting cups are more suitable for older infants (around 6-9 months) who are beginning to explore stacking, nesting, and grasping objects with more precision.
C) Crib mobile:
A crib mobile is an excellent developmentally appropriate toy for a 2-month-old infant. At this age, infants are developing visual tracking skills and are attracted to high-contrast patterns or moving objects. A crib mobile offers visual stimulation and can help an infant focus their eyes on objects, encouraging visual tracking and early sensory development. It is also safe for use in the crib environment.
D) Plastic keys:
Plastic keys can be a good toy for older infants as they begin developing their grasping and mouthing skills, but a 2-month-old infant is not yet able to hold objects or bring them to their mouth with coordination. Toys like these would not offer much benefit in terms of developmental stimulation at this age.
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