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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Hypernatremia: Hypernatremia (elevated sodium levels) is not typically associated with the emergent phase of burn injuries.
B. Hypercalcemia: Hypercalcemia (elevated calcium levels) is not typically associated with the emergent phase of burn injuries.
C. Hypermagnesemia: Hypermagnesemia (elevated magnesium levels) is not typically associated with the emergent phase of burn injuries.
D. Hyperkalemia: Hyperkalemia (elevated potassium levels) is a common electrolyte imbalance seen in the emergent phase of burn injuries due to the release of potassium from damaged cells.
It can lead to cardiac dysrhythmias and other complications if not promptly addressed.

A. Improves muscle strength B. Destroys the antibodies that cause MG C. Enhances immune system function D. Prevents excessive coughing

Correct Answer is A

Explanation

A. Correct. Neostigmine is an acetylcholinesterase inhibitor that improves muscle strength by increasing the availability of acetylcholine at the neuromuscular junction, thereby enhancing muscle contraction.
B. Incorrect. Neostigmine does not destroy the antibodies that cause MG. MG is an autoimmune disorder characterized by antibodies that block or destroy acetylcholine receptors, leading to muscle weakness.
C. Incorrect. Neostigmine does not enhance immune system function. It works specifically on the neuromuscular junction to improve muscle strength in MG.
D. Incorrect. While neostigmine may indirectly help prevent excessive coughing by improving respiratory muscle strength in clients with MG, preventing coughing is not its primary action.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has sustained a full-thickness burn and is in the emergent phase of the burn. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who has a new diagnosis of myasthenia gravis (MG) and a prescription for neostigmine. Which of the following information should the nurse include about the action of the medication?

Correct Answer is A

Explanation

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