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
The nurse should report the possible abuse to adult protective services if an older adult client states that their child took all their money. This is an important nursing intervention to ensure the safety and well-being of the client.
a) Instructing the client to report the theft to the police may be appropriate, but it is not the first action the nurse should take. The nurse has a legal and ethical obligation to report suspected abuse to the appropriate authorities.
c) Asking the client if there is another family member they can call for financial help may be appropriate, but it does not address the issue of possible abuse.
d) Restricting visitation for the client's family until discharge is not appropriate and may violate the client's rights.
Correct Answer is D
Explanation
When a mother states that she should have her baby latch on to both the nipple and areola during breastfeeding, it demonstrates an understanding of the correct latch technique. A proper latch involves the baby taking in not just the nipple but also a portion of the surrounding areola. This ensures effective milk transfer and helps prevent nipple soreness or damage.
"My baby should breastfeed 5 to 10 minutes on each breast": This statement is not entirely accurate. It is important to understand that breastfeeding duration can vary among infants, and there is no fixed timeframe for how long a baby should breastfeed on each breast. Some infants
may nurse for shorter periods, while others may take longer. The focus should be on ensuring that the baby is effectively nursing and getting enough milk rather than adhering strictly to a specific time limit.
"I should keep my baby on a strict feeding schedule": This statement is incorrect. Breastfeeding on demand, also known as responsive feeding, is generally recommended for newborns.
Newborns should be fed whenever they show signs of hunger, such as rooting, sucking motions, or increased alertness. Strict feeding schedules can interfere with the baby's natural feeding cues and hinder milk supply establishment.
"I should not wake my baby during the night to breastfeed": This statement is not accurate, especially for a 5-day-old newborn. Newborns typically need frequent feeding, including during the night, to meet their nutritional needs and support proper growth and development. It is generally recommended to wake a sleeping newborn every 2-3 hours during the night to ensure adequate feeding and prevent excessive weight loss.
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