A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Initiate one-to-one nursing observation.

Make a contract with the client for weight gain.

Administer the Hamilton depression scale.

Review the client's toxicology laboratory report.

Answer and Explanation

The Correct Answer is A

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Prevent the client from harming herself or others. Withdrawal from alcohol can lead to autonomic hyperactivity and is most concerning when it involves seizures, deliriums tremens, and hallucinations which can be potentially life-threatening. Therefore, the nurse's priority when caring for a client experiencing alcohol withdrawal is to prevent harm to the client by implementing seizure precautions and monitoring the client's vital signs.

Choice A, identifying the use of defense mechanisms, is an important aspect of treatment but can be addressed later.

Choice C, supporting the client's coping skills, is not a priority intervention.

A. Elderly tend to heal more slowly. B. The elderly person has a greater proportion of body surface area per amount of body mass. C. The elderly person has less physiological reserves. D. Elderly patients have thicker skin. E. Elderly patients have comorbidities.

Correct Answer is ["A","B","C","E"]

Explanation

The elderly tend to heal more slowly which can delay wound healing and increase the risk of infection. The elderly person has a greater proportion of body surface area per amount of body mass which increases the amount of skin available for injury, and thus the severity of the burn. The elderly person has less physiological reserves which makes it more difficult for the body to respond to injury and stress. Elderly patients have comorbidities such as diabetes, cardiovascular disease, and respiratory disease that can impair the body's ability to heal and increase the risk of complications. Elderly patients do not typically have thicker skin as it thins with age.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an alcohol use disorder and is experiencing withdrawal. Which of the following interventions is the nurse's priority?

Correct Answer is B

Explanation

The mortality rate for burns is highest in the elderly population. What factors put the very elderly at a high risk? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?

A nurse is caring for a client who has depressive disorder, is in alcohol withdrawal, and reports a recent job loss. Which of the following should be the priority nursing intervention?

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

A nurse is contributing to the plan of care for a child who has autism spectrum disorder. Which of the following interventions should the nurse recommend for the plan of care?

A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?

A nurse on an acute care mental health unit is caring for a client who has generalized anxiety disorder. The client received an upsetting telephone call and is now rapidly pacing the corridors of the unit. Which of the following actions should the nurse take?

A nurse is collecting data from an adolescent client who has anorexia nervosa. Which of the following findings should the nurse expect?