A nurse is caring for a client who is experiencing suicidal thoughts.
Which of the following actions should the nurse take?.
Place the client on 12-hour observation.
Remove harmful objects from the client's room.
Encourage visitors for the client at any time.
Encourage visitors to bring items to the client.
The Correct Answer is B
Choice A rationale:
Placing the client on 12-hour observation may not be sufficient as suicidal thoughts can persist beyond this timeframe.
Choice B rationale:
Removing harmful objects from the client’s room is a crucial step in ensuring the safety of a client experiencing suicidal thoughts. This action helps to minimize the risk of self-harm.
Choice C rationale:
While social support can be beneficial, it’s important to regulate visitors as they could unintentionally bring harmful objects or substances.
Choice D rationale:
Encouraging visitors to bring items could pose a risk as they might unknowingly bring in objects that could be used for self-harm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Extrapyramidal symptoms are a common adverse effect of haloperidol.
Choice B rationale:
Intractable hiccups are not typically associated with haloperidol.
Choice C rationale:
Fever is not a common side effect of haloperidol, but could indicate a serious condition like neuroleptic malignant syndrome.
Choice D rationale:
Excessive salivation is not typically a side effect of haloperidol.
Correct Answer is A
Explanation
Choice A rationale:
A serum lithium level of 1.6 mEq/L is above the therapeutic range (0.6-1.2 mEq/L) and can cause symptoms such as GI discomfort and poor coordination.
Choice B rationale:
Lip smacking and tongue thrusting are not typically associated with lithium toxicity.
Choice C rationale:
While blurred vision can be a symptom of lithium toxicity, jerking motor movements are not typically associated with this condition.
Choice D rationale:
Fever and fluctuating blood pressure are not typically symptoms of lithium toxicity.
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