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 A
Explanation
Answer: A
Rationale:
A) Ampicillin: Ampicillin is contraindicated for this client because it belongs to the penicillin class of antibiotics. Since the client is allergic to penicillin, administering ampicillin could trigger an allergic reaction, which could range from mild rash to severe anaphylaxis.
B) Erythromycin: Erythromycin is a macrolide antibiotic and can be used as an alternative for clients who are allergic to penicillin. It is often prescribed for group B streptococcus infections in penicillin-allergic clients, making it a suitable option in this case.
C) Cefazolin: Cefazolin is a cephalosporin antibiotic and is generally considered safe for clients with a penicillin allergy, except in cases of severe penicillin allergies. Cross-reactivity is low, and cefazolin can be an appropriate choice for treating group B streptococcus.
D) Clindamycin: Clindamycin is a lincosamide antibiotic and is often used for clients with penicillin allergies. It is effective against group B streptococcus and does not belong to the penicillin or cephalosporin classes, making it a suitable option for this client.
Correct Answer is B
Explanation
The client has state-sponsored health insurance: While information about the client's health insurance coverage is important for billing and financial purposes, it may not be directly relevant to the discussion in an interprofessional team meeting unless it specifically impacts the client's access to healthcare resources or affects decision-making regarding their care plan.
The reason for including this information is that difficulty ambulating can impact the client's overall mobility and functional status. It can have implications for their ability to perform activities of daily living, increase the risk of falls, and require additional interventions or resources. By sharing this information with the interprofessional team, appropriate strategies and interventions can be discussed and implemented to address the client's mobility issues.
The client's next dressing change is scheduled in 4 hours: The timing of the client's dressing change may be important for nursing documentation and scheduling purposes. However, it may not be a significant focus of discussion in an interprofessional team meeting unless there are specific concerns or issues related to the dressing change that require collaboration and coordination among the healthcare team.
The client's vital signs are checked every 8 hours: The frequency of vital sign checks is an important aspect of nursing care and monitoring. However, unless there are specific concerns or deviations from normal vital signs that need to be discussed, it may not be the primary information to include in an interprofessional team meeting. The focus of the meeting is typically on broader aspects of the client's condition, care plan, and multidisciplinary interventions.
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