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A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

Initiate one to one constant supervision around the clock.

Ensure the client's hands are always visible.

Tuck bedcovers over client's hands and arms.

Inspect the client's personal belongings.

Check the environment for possible hazards.

Assign the client to a private room.

Place only plastic utensils on the client's meal tray.

Answer and Explanation

Correct Answer : A,E

a. Initiate one to one constant supervision around the clock: A client who has attempted suicide is at high risk for further harm, and close monitoring is necessary to prevent further attempts. Initiation of one-to- one constant supervision around the clock ensures that the client is continuously monitored, and any signs of suicidal ideation or behavior can be immediately addressed.

e. Check the environment for possible hazards: It is important to check the client's environment for potential hazards, such as sharp objects, cords, or other items that could be used to harm oneself. This step helps to ensure the client's safety and prevent further attempts.

The other options are not appropriate or necessary in this situation:

b. Ensure the client's hands are always visible: This action may be necessary if the client has a history of self-harm or aggressive behavior, but it is not specifically related to preventing suicide attempts.

c. Tuck bedcovers over client's hands and arms: This action may be necessary if the client has a history of self-harm, but it is not specifically related to preventing suicide attempts.

d. Inspect the client's personal belongings: While it may be important to inspect the client's personal belongings for any items that could be used for self-harm, this action is not as urgent as initiating constant supervision and checking the environment for hazards.

f. Assign the client to a private room: While a private room may be beneficial for the client's comfort and privacy, it is not specifically related to preventing suicide attempts.

g. Place only plastic utensils on the client's meal tray: This action is not specifically related to preventing suicide attempts, unless there is concern that the client may harm themselves with utensils.

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Correct Answer is A

Explanation

Clonazepam is a benzodiazepine medication that acts quickly to reduce anxiety and promote relaxation. It is commonly used as a PRN medication for acute anxiety episodes.

Amitriptyline (Elavil) is a tricyclic antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action and potential for side eﬀects.

Olanzapine (Zyprexa) is an atypical antipsychotic medication that can be used to treat anxiety in certain cases, but it is not typically used as a PRN medication for acute anxiety episodes.

Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI) antidepressant that is not typically used as an as-needed anxiolytic medication due to its slow onset of action. It is usually taken on a daily basis to provide ongoing anxiety relief.

A. Sudden unexplained loss of vision B. Constant worry about the undiagnosed presence of an illness for more than 6 months C. Obsession over a fictitious defect in physical appearance D. Prior physical health followed by the need for two surgeries within the last three months

Correct Answer is B

Explanation

Generalized anxiety disorder (GAD) is a type of anxiety disorder characterized by excessive and persistent worry about a variety of diﬀerent things, including health, work, relationships, and everyday situations. People with GAD may experience physical symptoms, such as fatigue, muscle tension, and restlessness.

Option a is not a typical finding associated with GAD. Sudden unexplained loss of vision may be a symptom

of a neurological or ophthalmologic condition, but not specifically related to GAD.

Option c describes a condition called body dysmorphic disorder (BDD), which is a type of obsessive- compulsive disorder characterized by an excessive preoccupation with a perceived physical ﬂaw. BDD is not typically associated with GAD.

Option d does not describe a typical finding associated with GAD. While physical health issues can contribute to anxiety, the need for surgeries within the last three months is not necessarily indicative of GAD.

Therefore, the correct option is b. Constant worry about the undiagnosed presence of an illness for more than 6 months. People with GAD often worry about their health and the possibility of having an undiagnosed illness, even when there is no evidence of a problem. This worry may persist for six months or more and can interfere with daily life.

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A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?

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