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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A systolic blood pressure of 62 mm Hg indicates severe hypotension and is a medical emergency. This is a life-threatening situation that requires immediate hospitalization for stabilization and treatment. Clients with eating disorders are at risk of electrolyte imbalances, cardiac complications, and other medical complications due to malnutrition and dehydration. While the other options are also abnormal findings, they are not as severe as the critically low blood pressure measurement. Therefore, the priority for hospitalization would be the client with severe hypotension.
Correct Answer is A
Explanation
This technique is known as reflective listening or active listening, and it involves paraphrasing what the patient has said to show that the nurse is actively listening and trying to understand the patient's feelings and thoughts. It demonstrates empathy and helps to build trust between the nurse and patient.
Option b is not effective because giving advice and opinion can convey a lack of interest in the patient's feelings and thoughts.
Option c is not ideal because it is a closed-ended question that may limit the patient's response.
Option d may also seem insincere and may not reflect a genuine interest in the patient's concerns.
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