A nurse is caring for a client following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions is the nurse's priority?
Initiating suicide precautions
Administering the Hamilton Depression Scale
Making a contract with the client for eating behavior
Reviewing the client's toxicology laboratory report
The Correct Answer is A
In this scenario, the nurse's priority should be initiating suicide precautions. Safety is of utmost importance when caring for a client following a suicide attempt. By implementing suicide precautions, the nurse can take steps to ensure the client's physical and emotional well-being, such as removing potential means of self-harm and closely monitoring the client's behavior. This action aims to prevent further harm and promote a safe environment for the client.
Incorrect:
B- Administering the Hamilton Depression Scale: While assessing the client's level of depression is important, it is not the priority in this situation. The client has just attempted suicide, indicating a high level of risk. Therefore, the nurse should prioritize safety measures and immediate interventions rather than administering a depression scale.
C- Making a contract with the client for eating behavior: While addressing the client's eating behavior is important, it is not the priority in this situation. The client has just attempted suicide, indicating a significant risk to their life. Ensuring their safety and providing appropriate mental health support take precedence over addressing their eating behavior.
D- Reviewing the client's toxicology laboratory report: While reviewing the client's toxicology report may provide valuable information about substance abuse, it is not the priority in this scenario. The immediate concern is the client's safety following a suicide attempt. The nurse should focus on implementing suicide precautions and addressing the client's emotional and physical well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Tremors: This choice is correct. Tremors or muscle twitching can be expected in a client experiencing acute cocaine toxicity. Cocaine is a central nervous system stimulant that can cause overstimulation of muscles, resulting in tremors.
Incorrect:
A- Hypothermia: This choice is incorrect. Acute cocaine toxicity is associated with an increase in body temperature (hyperthermia) rather than a decrease (hypothermia). Cocaine is a stimulant that can cause the body to overheat, leading to hyperthermia, which is a dangerous condition that requires immediate medical attention.
B- Hypotension: This choice is incorrect. Cocaine is a stimulant that increases blood pressure and heart rate, leading to hypertension (high blood pressure), not hypotension (low blood pressure). Hypertension is a common cardiovascular effect of cocaine use.
D- Respiratory depression: This choice is incorrect. Respiratory depression, which is a slowing of the respiratory rate and depth, is more commonly associated with depressant drugs like opioids or benzodiazepines. As a stimulant, cocaine tends to have the opposite effect, leading to increased respiratory rate (tachypnea) and sometimes hyperventilation.
Correct Answer is B
Explanation
This response acknowledges the client's effort and self-care without making assumptions or imposing judgment. It is an open and non-intrusive statement that shows the nurse is paying attention to the client's appearance and recognizing their positive action of self-grooming. It allows the client to share their feelings or thoughts if they choose to without feeling pressured or judged. This response demonstrates empathy and understanding, creating a supportive and non-threatening environment for the client to express themselves if they wish to do so.
Incorrect:
A- "Why are you all dressed up today?" This question may put the client on the spot and make them feel self-conscious or defensive. It assumes that there must be a specific reason for the client's appearance, which may not be the case. It can also imply that the client's usual appearance is different or not as desirable.
C- "Everyone feels better after showering." While it is true that personal hygiene can have a positive impact on one's mood, this statement may come across as dismissive or oversimplifying the client's experience. It may invalidate any underlying emotions or struggles the client is facing with their depression. It is important to acknowledge and address the client's feelings rather than making broad generalizations.
D- "You must be getting better. You look great." This statement assumes that physical appearance is directly correlated with the client's mental health and suggests that improvement in appearance equates to improvement in mental well-being. However, a person's outward appearance may not accurately reflect their internal struggles or progress in managing depression. Additionally, it can create pressure for the client to maintain a certain appearance to be perceived as "better."
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