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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Free Nursing Study Resources

Correct Answer is C

Explanation

A) "The client should use a hair dryer on a warm setting to relieve itching inside the cast.": Using a hair dryer on a warm setting to relieve itching inside the cast is not recommended because it could potentially lead to burns or skin irritation. The client should avoid inserting objects inside the cast to scratch, as this could damage the skin or cause an infection.

B) "The client can shower with the cast after 24 hr.": A plaster cast is not waterproof, and the client should avoid getting it wet. Although the cast may feel dry on the outside after 24 hours, it typically takes about 48 hours or longer for a plaster cast to fully dry and harden. Showering with a plaster cast is not safe, as moisture could cause skin irritation or lead to the development of sores or infection.

C) "The client’s extremity should be elevated after the cast is applied.": Elevating the extremity after a cast is applied is a key teaching point to help reduce swelling and improve circulation. This is especially important during the first 24 to 48 hours after cast application. Elevation helps to prevent or manage swelling, which can be a common complication after an injury and cast application.

D) "The client should keep the cast covered until it is dry.": While it is important to keep a cast clean and dry during the drying process, the cast should not be covered with plastic or other materials that could trap moisture. The cast needs air circulation to dry properly, and covering it could lead to the cast becoming too moist, increasing the risk of skin issues or infection.

A. Prolonged PT/INR B. Elevated lipase C. Decreased albumin D. Elevated ammonia

Correct Answer is B

Explanation

A) Prolonged PT/INR:
A prolonged PT/INR is typically associated with liver dysfunction or clotting disorders. While pancreatitis can lead to complications like bleeding, it does not directly cause a prolonged PT/INR. In the case of pancreatitis, the main concerns are related to enzymes, fluid and electrolyte imbalances, and potential organ dysfunction, but clotting issues are not a primary diagnostic feature.

B) Elevated lipase:
This is the most characteristic lab finding in pancreatitis. Lipase is an enzyme produced by the pancreas, and its levels rise significantly when the pancreas is inflamed. Elevated lipase levels are a key diagnostic indicator of pancreatitis, often seen alongside elevated amylase levels. This finding helps confirm the diagnosis and monitor the severity of the condition.

C) Decreased albumin:
Decreased albumin levels are typically seen in conditions that affect liver function, kidney disease, or malnutrition. While pancreatitis can lead to some degree of malnutrition or fluid shifts, a decreased albumin level is not a specific or expected finding in pancreatitis itself. The focus is more on enzyme levels and possible complications like hypocalcemia or hyperglycemia.

D) Elevated ammonia:
Elevated ammonia levels are generally indicative of liver dysfunction or hepatic encephalopathy, which occurs in severe liver disease. While pancreatitis can cause systemic complications, an elevated ammonia level is not a typical lab finding associated with pancreatitis. Ammonia is more commonly monitored in cases of liver failure or cirrhosis.

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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

A nurse is reinforcing teaching with a client who is to have plaster cast applied to his right arm. Which of the following information should the nurse include the teaching?

Correct Answer is C

Explanation

A nurse is reviewing laboratory findings for three clients. Which of the following laboratory results should the nurse expect for a client has pancreatitis?

Correct Answer is B

Explanation

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