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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
"I call a friend who makes me smile and laugh," and "I tense and release my muscles, starting with my feet." These are adaptive coping strategies that help to reduce stress and promote relaxation. Calling a friend who makes you smile and laugh, for example, can help to distract from negative thoughts and promote positive emotions. Tense and release exercises can help to reduce muscle tension and promote relaxation.
Choice A, "I sleep in in the mornings," is not an adaptive coping strategy because it doesn't address the source of stress and may actually lead to avoidance.
Choice B, "I isolate myself in my room for a few hours when things get overwhelming," is not adaptive because it promotes social withdrawal and avoidance.
Choice D, "I think about being on my favorite beach vacation," is not adaptive because it promotes avoidance and doesn't address the source of stress.
Correct Answer is B
Explanation
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.
Therefore, these are not indications for further teaching.
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