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.

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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. "I was monitoring my blood glucose every 3 to 4 hours." B. "I had to stop my insulin." C. "I called the doctor because of these symptoms." D. None of the above.

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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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 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?

Correct Answer is B

Explanation

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A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)

A nurse in a community clinic is speaking to other nurses about risk factors for domestic violence. Which of the following statements by one of the other nurses indicates the need for further teaching?

A nurse is caring for a client with whom he has developed a therapeutic relationship and who will be discharged later in the day. The client thanks the nurse for his help during the hospitalization. Which of the following responses should the nurse make?

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

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

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