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
A. Serve meals with plastic utensils: Clients who have attempted suicide are at risk of self-harm. Using plastic utensils reduces the risk of injury from sharp objects and is an immediate safety intervention to prevent further attempts. This is a standard precaution in suicide precautions.
B. Assign another client to accompany the client to therapy sessions: Clients at risk for suicide should be supervised by staff, not other clients. Relying on peers does not ensure safety and may place both clients at risk, making this an inappropriate intervention.
C. Assign the client to a private room: While privacy can provide comfort, placing a high-risk client in a private room without adequate observation increases the risk of unnoticed self-harm. Clients at risk for suicide require close monitoring and a safe environment with staff visibility.
D. Check on the client every 4 hr: Suicide precautions require frequent observation, often continuous or at least every 15–30 minutes depending on risk level. Checking every 4 hours is insufficient and does not adequately ensure client safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["360"]
Explanation
- Convert ounces to milliliters
Ice cream: 4 oz × 30 mL/oz = 120 mL
Coffee: 8 oz × 30 mL/oz = 240 mL
- Calculate total fluid intake
Total intake = 120 + 240
Total intake = 360 mL
Correct Answer is B
Explanation
A. "You should follow the label directions based on your child's weight.": While dosing medications based on weight is generally appropriate, aspirin is not recommended for children or adolescents due to the risk of Reye’s syndrome, a rare but serious condition affecting the liver and brain after viral infections.
B. "You should avoid administering aspirin to your child.": This is the safest and most accurate response. Aspirin should not be given to children under 18, particularly following viral illnesses or immunizations, because of the association with Reye’s syndrome. Acetaminophen or ibuprofen are preferred for fever management in toddlers.
C. "Your child will require an antibiotic if she develops a fever.": Fever after immunization is usually a benign, self-limited response. Antibiotics are not indicated unless there is evidence of a bacterial infection. Providing this information could cause unnecessary concern or inappropriate antibiotic use.
D. "Your child can have two baby aspirins every 4 hours.": Recommending aspirin in a toddler is unsafe due to the risk of Reye’s syndrome. Providing a specific dose encourages potentially harmful practice and is contraindicated in pediatric care.
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