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 A
Explanation
- Rationale for A: The name and medical record number are unique identifiers that are used to accurately match a newborn with their medical records and ensure that the correct medication is administered. This method of identification minimizes the risk of medical errors, which is crucial in a hospital setting where multiple newborns may be present.
- Rationale for B: While the birth date and mother's name are important, they may not be as effective for identification because multiple newborns could share a birth date, and there could be more than one mother with the same name in the maternity ward.
- Rationale for C: Age and diagnosis are not specific enough for the identification of a newborn when administering medication. Age is not a distinguishing factor in a neonatal unit, and the diagnosis could apply to multiple infants.
- Rationale for D: Footprints and identification number can be used as secondary identifiers. However, footprints may change rapidly as the newborn grows, and the identification number should be cross-referenced with the name and medical record number for accurate identification.
Correct Answer is D
Explanation
A. Incorrect. Upper gastrointestinal series typically involve oral ingestion of a contrast medium, not an injection.
B. Incorrect. Clients are usually instructed to fast before an upper gastrointestinal series, not consume breakfast.
C. Incorrect. While it's generally advisable to have someone accompany the client for procedures involving sedation or anesthesia, fluoroscopy itself does not usually require sedation, and the client can typically drive home afterward.
D. Correct. Prior to an upper gastrointestinal series, clients are usually required to drink a contrast medium to outline the digestive tract for fluoroscopy imaging.
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