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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?

Implement continuous one-to-one observation.

Encourage the client to participate in group therapy.

Ask the client to sign a no-suicide contract.

Establish a rapport to foster trust.

Answer and Explanation

The Correct Answer is A

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

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Correct Answer is C

Explanation

Aripiprazole is an atypical antipsychotic medication that can lower the seizure threshold and increase the risk of seizures in clients who have a seizure disorder. Therefore, it is contraindicated for these clients. The other conditions are not contraindications for aripiprazole therapy.

A. Lanugo covering the body B. +2 edema of the lower extremities C. BUN 21 mg/dL D. Blood pH 7.60

Correct Answer is D

Explanation

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who is to begin taking aripiprazole. The nurse should identify that which of the following findings is a contraindication for aripiprazole therapy?

Correct Answer is C

Explanation

A nurse is caring for a client who has anorexia nervosa. Which of the following findings requires immediate intervention by the nurse?

Correct Answer is D

Explanation

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