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.
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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Related Questions
Correct Answer is B
Explanation
The correct answer is B. Allow the client unlimited time for the grieving process.
Choice A reason:
Changing the subject when the client becomes upset may prevent the client from expressing their feelings and could hinder their emotional processing. This is not a recommended approach as it may lead to unresolved grief and emotional distress.
Choice B reason:
Allowing the client unlimited time for the grieving process aligns with the principles of palliative care, which focuses on enhancing a patient's quality of life and providing relief from the symptoms and stress of serious illness. It's important to give the client the time and space they need to process their emotions.
Choice C reason:
Discouraging the client from forming new relationships could lead to social isolation and negatively impact their emotional well-being. It's important for the client to have a support system during this difficult time.
Choice D reason:
Offering advice about various treatment choices is not the nurse's role. The nurse should provide information and support, but the decision-making should be patient-centered. It's important to respect the client's autonomy and decisions regarding their care.
Correct Answer is D
Explanation
Cocaine is a stimulant that can cause paranoia, increased heart rate, and elevated blood pressure in high doses or during acute intoxication.
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