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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The subjective indication that the client needs PRN (as needed) pain medication is when the client reports pain. Pain is a subjective experience, and it is essential to address the client's self-reported pain level and provide appropriate pain management.
Explanation for the other options:
a) The client's heart rate is 110/min: An increased heart rate can be an objective indication of pain, but it is not a subjective indication. Subjective indications are based on the client's self-report or personal experiences.
b) The client is guarding their abdominal incision: Guarding the abdominal incision may suggest discomfort or pain, but it is an objective indication that can be observed by the nurse. Subjective indications focus on the client's self-report.
c) The client exhibits facial grimacing: Facial grimacing can be an objective indication of pain, but it is not a subjective indication. Again, subjective indications are based on the client's self-report or personal experiences.
In this scenario, the most reliable and appropriate indication for administering PRN pain medication is when the client reports pain, as this acknowledges the client's own perception of their pain level.
Correct Answer is A
Explanation
a ."I will take a stool softener to prevent constipation."
Explanation:
The statement that indicates an understanding of the instructions is "I will take a stool softener to prevent constipation."
Explanation for the other options:
b. "I will ask to work the night shift, so I will not be driving in bright sunlight."
This statement is incorrect. The need to work the night shift to avoid bright sunlight does not relate to the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The primary focus of discharge teaching for this condition would be related to eye care, medication administration, and follow-up appointments.
c. "I will need to use my eye drops for 1 year."
This statement is incorrect. While eye drops are commonly prescribed for open-angle glaucoma, the duration of their use can vary based on the individual's condition and the healthcare provider's instructions. The client should follow the specific instructions given by their healthcare provider regarding the frequency and duration of eye drop use.
d. "I will need to follow a low-protein diet."
This statement is incorrect. A low-protein diet is not typically part of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma. The focus of dietary recommendations for open-angle glaucoma is on maintaining a healthy diet and managing other health conditions that may affect intraocular pressure, such as high blood pressure or diabetes.
In summary, the statement that demonstrates an understanding of the discharge instructions for a client postoperative following laser surgery for open-angle glaucoma is "I will take a stool softener to prevent constipation." This indicates the client's awareness of the importance of preventing constipation, which can be a side effect of some medications prescribed after surgery.
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