A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first?

Document the client's mood and affect.

Search the client's personal belongings.

Attend an interdisciplinary team meeting.

Assign the client to a semi-private room.

Answer and Explanation

The Correct Answer is B

A. Document the client’s mood and affect.
Important, but not the first action.

B. Search the client’s personal belongings.
Safety comes first. The priority is removing any items that could be used for self-harm.

C. Attend an interdisciplinary team meeting.
Will occur later-client’s immediate safety takes priority.

D. Assign the client to a semi-private room.
Private rooms are preferred to allow better monitoring and safety checks.

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Correct Answer is C

Explanation

A. Number scale
Requires verbal communication and abstract reasoning, not appropriate for advanced dementia.

B. Color scale
Also requires cognitive recognition that may be impaired in dementia.

C. Behavioral pain scale
This scale assesses pain using facial expression, body movements, and vocalizations.

D. Pieces of pain scale
This is generally used for pediatric clients, not those with dementia.

A. A client who is 4 days postpartum and has lochia serosa B. A client who is 3 days postpartum and has not had a bowel movement since prior to admission C. A client who is 1 day postpartum and has not voided in 8 hr D. A client who is 2 days postpartum and whose fundus is 2 to 4 cm below the umbilicus

Correct Answer is C

Explanation

A. A client who is 4 days postpartum and has lochia serosa
This is an expected finding in the healing process.

B. A client who is 3 days postpartum and has not had a bowel movement
Common postpartum; not urgent unless severe discomfort or obstruction is present.

C. A client who is 1 day postpartum and has not voided in 8 hr
Urinary retention increases the risk of uterine atony and postpartum hemorrhage-must be addressed urgently.

D. A client whose fundus is 2–4 cm below the umbilicus on day 2
Normal involution of the uterus; not concerning.

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A nurse is assisting with the admission of a client to an acute-care unit following a suicide attempt. Which of the following actions should the nurse take first?

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