A nurse is caring for a client who attempted 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
- Rationale for A: Serving meals with plastic utensils is a safety measure to prevent self-harm. Metal utensils can be used as weapons, so plastic is a safer alternative. This action reflects the priority of maintaining a safe environment for the client.
- Rationale for B: Assigning another client to accompany the client to therapy sessions is not advisable. It may violate privacy and confidentiality, and it is not the responsibility of other clients to monitor safety.
- Rationale for C: Assigning the client to a private room could be beneficial for monitoring purposes, but it does not directly prevent self-harm. It is also important to consider that constant observation is necessary regardless of room assignment.
- Rationale for D: Checking on the client every 4 hours is not sufficient for a client who is at high risk for suicide. More frequent monitoring is needed to ensure the client's safety and to intervene promptly if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A client who has a head injury and whose pupils are fixed and dilated: This client likely has a severe head injury with signs of increased intracranial pressure, which requires urgent intervention. However, airway and breathing take precedence over neurological status in triage. B. A client who has a dislocated shoulder and reports a pain level of 8 on a scale from 0 to 10: While this client is in pain, dislocated shoulder is not immediately life-threatening in the context of a mass casualty situation.
C. A client who has a 20.3-cm (8-in) scalp laceration with intermittent bleeding: Although this client has a significant laceration, it is not immediately life-threatening compared to compromised breathing.
D. A client who has diminished breath sounds and paradoxical chest movement: This client is likely experiencing a tension pneumothorax, a life-threatening condition that requires immediate intervention to decompress the chest and restore normal breathing.
Correct Answer is D
Explanation
A. The adolescent brother criticizing the parents' plan for a funeral service might indicate a coping mechanism or emotional response but is not a typical response.
B. The school-age sister viewing death as a type of temporary sleep demonstrates a common misconception about death in children but is not necessarily the most likely response from siblings.
C. The adolescent brother fearing the terminal illness is contagious might occur due to a lack of understanding or misinformation but is not a common response among siblings.
D. The school-age sister being concerned about the impact of her sibling's death on herself is a common response. Siblings often have concerns about their own feelings and the changes that will occur within the family dynamic after the loss of a sibling.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.