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 D
Explanation
Choice A rationale:
Drinking green tea does not directly cause lithium toxicity.
Choice B rationale:
Moderate exercise does not directly cause lithium toxicity.
Choice C rationale:
Increasing sodium intake does not directly cause lithium toxicity. In fact, a sudden decrease in sodium intake can increase the risk of lithium toxicity.
Choice D rationale:
Experiencing diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium.
Correct Answer is B
Explanation
Choice A rationale:
Increased flatulence is not typically associated with lithium toxicity.
Choice B rationale:
Vomiting is a common symptom of lithium toxicity, indicating the client understands the teaching.
Choice C rationale:
While loss of appetite can occur in various conditions, it’s not a specific indicator of lithium toxicity.
Choice D rationale:
Headaches can be caused by various factors and are not specifically associated with lithium toxicity.
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