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) Decreased platelets: A decrease in platelet count (thrombocytopenia) is often associated with conditions such as bleeding disorders, bone marrow problems, or certain infections, but it is not a direct indicator of infection. While infections can cause a drop in platelets, this is not a specific or primary indicator of infection.

B) Decreased hemoglobin: A decrease in hemoglobin is typically indicative of anemia, which can result from a variety of causes, including nutritional deficiencies, chronic disease, or blood loss. While anemia can be associated with some infections, it is not a specific indicator of infection.

C) Increased erythrocyte sedimentation rate (ESR): An increased ESR is a nonspecific indicator of inflammation in the body and can be associated with infections, autoimmune diseases, and other inflammatory conditions. It is commonly elevated during infections, as the body responds to the inflammatory process. Therefore, an elevated ESR is a useful laboratory finding when suspecting an infection.

D) Increased iron level: Increased iron levels are typically associated with conditions such as hemochromatosis or iron overload, not with infections. During infections, iron levels can actually decrease due to the body's response to restrict iron availability to pathogens.

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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Body system	Findings
Head. Eyes. Ears. Nose, and Throat (HEENT)	Yellowing of the eyes Blurred vision Dry eyes
Gastrointestinal	Abdominal pain Weight gain
Hematologic	Increased bruising Increased bleeding tendancies Insomnia
Genitourinary	Darkening of the urine Urinary frequency

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Nursing Test Bank

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