A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?
Ask the client to sign a no-suicide contract.
Implement continuous one-to-one observation.
Establish a rapport to foster trust.
Encourage the client to participate in group therapy.
The Correct Answer is B
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.Weighing the client every other day might not be appropriate in this case. Individuals with binge eating disorder often struggle with body image issues, and focusing on weight can exacerbate these concerns and contribute to a negative psychological state.
B. Remain with the client for 1 hr after meals: This can help prevent the client from engaging in purging behaviors after eating.
C.Involving the client in meal planning can help them feel more in control and promote healthier eating habits.While meal planning can be beneficial, it's not the most immediate action needed in this situation.
D.Offering snacks when the client is hungry can potentially worsen the disorder. Clients with binge eating disorder often struggle with impulse control and may have difficulty stopping themselves from overeating. Providing unlimited access to snacks may reinforce unhealthy eating patterns.
Correct Answer is B
Explanation
A. Check the client's condition after the procedure. - This task should not be delegated to assistive personnel (AP) as it requires assessment skills that are within the nurse's scope of practice.
B. Assist the client to ambulate for the first time following the procedure. - This is a task that can be delegated to AP. Ambulation assistance is within the AP's scope of practice, provided the nurse has assessed the client's stability beforehand.
C. Witness the client's signature on the consent for the procedure. - This task must be performed by a nurse or another licensed healthcare provider, as it involves ensuring that the client has given informed consent.
D. Give the client atropine 30 min before the procedure. - Administering medication is within the nurse's scope of practice and should not be delegated to AP.
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