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
Hyponatremia refers to a lower-than-normal level of sodium in the blood. Sodium is an essential electrolyte involved in various bodily functions, including maintaining fluid balance and transmitting nerve impulses. When sodium levels are low, it can lead to fluid imbalances, affecting the function of muscles and nerves. Muscle cramps are a common manifestation of hyponatremia and occur due to alterations in muscle excitability and contractility.
Constipation: Constipation is not typically associated with hyponatremia. It can occur due to various reasons, such as dietary factors, lack of physical activity, or other medical conditions, but it is not a direct consequence of low sodium levels.
Hypertension: Hyponatremia is not usually associated with hypertension (high blood pressure). Hypertension can be caused by several factors, including genetics, lifestyle, and certain medical conditions, but it is not directly related to low sodium levels.
Blurred vision: While blurred vision can occur in some medical conditions, such as diabetes or certain eye disorders, it is not a typical finding in hyponatremia. Visual disturbances are not a direct consequence of low sodium levels.
Correct Answer is D
Explanation
Answer: (D) Refrigerate the specimen until the time of transport to the laboratory
Rationale:
A) Collect 2 ml of sputum in an emesis basin: While it is important to collect an adequate volume of sputum, using an emesis basin is inappropriate for collecting a specimen for culture and sensitivity. Sputum must be collected in a sterile container to avoid contamination, ensuring the accuracy of the culture results.
B) Instruct the client to rinse with an antiseptic mouthwash prior to specimen collection: Using an antiseptic mouthwash before collecting a sputum specimen is not recommended, as it could contaminate the sample with antiseptic agents, potentially affecting the growth of microorganisms in the culture. The client should rinse with plain water instead.
C) Swab the oropharynx with a sterile swab: Swabbing the oropharynx is more appropriate for collecting a throat culture rather than a sputum specimen. Sputum collection requires the client to expectorate mucus from the lower respiratory tract, not from the oropharynx, to obtain an accurate sample for culture and sensitivity.
D) Refrigerate the specimen until the time of transport to the laboratory: Refrigerating the sputum specimen is crucial to preserve the integrity of the sample and inhibit the growth of contaminants before it is transported to the laboratory. This action helps ensure that the results of the culture and sensitivity test are accurate.
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