A nurse is caring for several clients who are attending community-based mental health programs. Which Of the following clients should the nurse plan to visit first?
Select one:
A client who recently burned her arm by accident while using a hot iron at home.
A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview.
A client who requests that her antipsychotic medication be changed due to some new adverse effects.
A client that says he is hearing a voice that tells him he is not worthy of living anymore.
The Correct Answer is D
This client is experiencing auditory hallucinations and may be at risk for self-harm or suicide. The nurse should prioritize visiting this client first to assess their safety and provide appropriate interventions.
Option a. A client who recently burned her arm by accident while using a hot iron at home may require wound care and education on safety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option b. A client who tells the nurse he experienced manifestations of severe anxiety before and during a job interview may benefit from interventions to manage anxiety, but this situation is not as urgent as the client experiencing auditory hallucinations.
Option c. A client who requests that her antipsychotic medication be changed due to some new adverse effects may require medication adjustment and monitoring for side effects, but this situation is not as urgent as the client experiencing auditory hallucinations.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Autonomy is the ethical principle that upholds an individual's right to self-determination and decision- making regarding their own life and treatment. In this case, the unit manager's policy of allowing clients to make their own choice about whether or not to attend group therapy preserves the principle of autonomy.
By not mandating group therapy, the unit manager respects the clients' right to make decisions about their own treatment and encourages them to participate in a way that feels comfortable and aligned with their own goals and values. This promotes a sense of empowerment and self-efficacy in clients, which is important for their overall recovery and well-being.
While beneficence, non-maleficence, and justice are also important ethical principles in healthcare, they are not directly applicable to this particular situation.
Correct Answer is ["A","E"]
Explanation
a. Initiate one to one constant supervision around the clock: A client who has attempted suicide is at high risk for further harm, and close monitoring is necessary to prevent further attempts. Initiation of one-to- one constant supervision around the clock ensures that the client is continuously monitored, and any signs of suicidal ideation or behavior can be immediately addressed.
e. Check the environment for possible hazards: It is important to check the client's environment for potential hazards, such as sharp objects, cords, or other items that could be used to harm oneself. This step helps to ensure the client's safety and prevent further attempts.
The other options are not appropriate or necessary in this situation:
b. Ensure the client's hands are always visible: This action may be necessary if the client has a history of self-harm or aggressive behavior, but it is not specifically related to preventing suicide attempts.
c. Tuck bedcovers over client's hands and arms: This action may be necessary if the client has a history of self-harm, but it is not specifically related to preventing suicide attempts.
d. Inspect the client's personal belongings: While it may be important to inspect the client's personal belongings for any items that could be used for self-harm, this action is not as urgent as initiating constant supervision and checking the environment for hazards.
f. Assign the client to a private room: While a private room may be beneficial for the client's comfort and privacy, it is not specifically related to preventing suicide attempts.
g. Place only plastic utensils on the client's meal tray: This action is not specifically related to preventing suicide attempts, unless there is concern that the client may harm themselves with utensils.
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