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

Answer and Explanation

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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Correct Answer is D

Explanation

Answer: D. "Clean the prosthesis using a damp, soapy cloth."

Rationale:

A. "Keep initial pressure dressing in place for 1 week after surgery":
The pressure dressing is typically changed more frequently to monitor the incision site for signs of infection and to ensure appropriate healing. Keeping it in place for a week without monitoring could increase the risk of infection and complications.

B. "Leave the prosthesis in place when going to bed":
It is generally recommended to remove the prosthesis at night to allow the residual limb to rest and prevent skin irritation or pressure sores. Leaving it on overnight can lead to unnecessary strain on the limb.

C. "Avoid extension of the hips when lying down":
Clients should actually avoid prolonged hip flexion, not extension, as it can lead to hip contractures. Instead, they should try to lie prone periodically to stretch the hip and reduce the risk of contracture formation.

D. "Clean the prosthesis using a damp, soapy cloth":
Using a damp, soapy cloth to clean the prosthesis helps maintain hygiene and prevents skin irritation. It's important to keep the prosthesis clean to avoid any buildup of bacteria or dirt, which can affect both the device and the residual limb’s health.

A. Encourage strength-training exercise. B. Increase the client's fluids to 4 L per day. C. Increase protein in the diet. D. Encourage the client to have continual bed rest.

Correct Answer is C

Explanation

Answer: C

Rationale:

A) Encourage strength-training exercise: Strength-training exercises can be beneficial in building muscle mass and improving overall strength. However, for a client with leukemia experiencing chronic fatigue, this may be too strenuous and could exacerbate their fatigue rather than alleviate it. It is better to encourage light to moderate activities based on their tolerance.

B) Increase the client's fluids to 4 L per day: While adequate hydration is important, increasing fluids to 4 L per day may not be suitable for all clients and could pose risks, particularly if there are concerns about fluid balance or renal function. This recommendation should be tailored to the client's specific needs and medical condition.

C) Increase protein in the diet: Increasing protein in the diet can help improve energy levels and support the body's repair and regeneration processes. For clients with leukemia who are experiencing chronic fatigue, a high-protein diet can aid in maintaining muscle mass and overall nutritional status, helping to combat fatigue.

D) Encourage the client to have continual bed rest: Encouraging continual bed rest can lead to deconditioning and further exacerbate fatigue. It is important to balance rest with periods of gentle activity to maintain some level of physical function and avoid complications such as muscle atrophy or deep vein thrombosis.

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A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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