A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?
Serve meals with plastic utensils.
Assign another client to accompany the client to therapy sessions
Assign the client to a private room
Check on the client every 4 hr
The Correct Answer is A
Answer: A
Rationale:
A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.
B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.
C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.
D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
b. A decreased level of consciousness and vomiting
Explanation:
When receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. This combination of symptoms suggests a potentially serious condition that requires immediate atention and assessment. It could indicate a neurological or gastrointestinal issue, and further evaluation is necessary to determine the underlying cause and provide appropriate interventions.
Explanation for the other options:
a. Cellulitis accompanied by a low-grade fever:
While cellulitis and a low-grade fever require atention, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should prioritize assessing the client with altered consciousness and vomiting due to the potential for more urgent interventions.
c. A pain rating of 7 on a scale from 0 to 10 after receiving analgesia 30 min ago:
Although the client's pain rating of 7 indicates ongoing pain, it is not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first address the client with altered consciousness to determine the cause and provide appropriate interventions before assessing and managing pain in other clients.
d. Type 2 diabetes mellitus and a blood glucose level of 160 mg/dL:
While elevated blood glucose levels in a client with type 2 diabetes require atention and management, they are not as immediately critical as a decreased level of consciousness and vomiting. The nurse should first assess the client with altered consciousness to identify the cause and provide prompt interventions.
In summary, when receiving report on four clients, the nurse should first collect data about the client who has a decreased level of consciousness and vomiting. These symptoms indicate a potentially serious condition requiring immediate assessment and intervention.
Correct Answer is C
Explanation
Answer: C
Rationale:
A) Apply a topical corticosteroid ointment to the scalp: Corticosteroids are not indicated for the treatment of Pediculosis capitis (head lice). The treatment focuses on eliminating the lice and nits, typically through pediculicide medications like permethrin or ivermectin. Corticosteroids are used to reduce inflammation and itching, but they do not kill the lice or their eggs.
B) Soak hair brushes and combs in soapy water: Soaking hair brushes and combs in soapy water alone is not sufficient to kill lice. Items such as hair brushes should be soaked in hot water (130°F or higher) for at least 5-10 minutes to ensure any lice or nits present are killed. This is a critical step to prevent reinfestation.
C) Wash the bed linens in hot water: Washing bed linens in hot water (130°F or higher) is essential to eliminate lice and nits that may have transferred onto bedding. This prevents the spread and recurrence of lice. Items that cannot be washed should be sealed in a plastic bag for 2 weeks to kill the lice.
D) Clean the child's toys with a 1:10 bleach solution: Lice are spread through direct contact and cannot live on inanimate objects for long periods. Cleaning toys with bleach is unnecessary for lice removal and can be harmful to the toys or the child if not properly rinsed.
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