A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

"Can you tell me about the stresses in your life?"

"Has anyone in your family ever died by suicide?

“Do you have a plan for harming yourself?"

“Do you have someone to discuss your feelings with?"

Answer and Explanation

The Correct Answer is C

Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.

While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.

The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.

Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.

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Correct Answer is B

Explanation

In Islam, it is customary to position the deceased's head toward Mecca, which is considered the holiest city in Islam. Mecca is the direction toward which Muslims face during prayer. Orienting the client's head toward Mecca is a sign of respect for their religious beliefs and customs.

While it is common in some cultural and religious practices for family members to stay with the deceased until burial, this may vary depending on the specific beliefs and customs of the family. It is important to respect the family's wishes and cultural practices, but it is not solely specific to Islam.

The duration of time for a family member to stay with the deceased can vary depending on cultural and religious practices, but there is no specific set duration of 8 hours in Islamic customs.

In Islam, the direction of Mecca is significant, and positioning the client's head toward Mecca is the customary practice. There is no specific requirement to position the head northward in Islamic customs.

A. Release the client's restraints every 4 hr. B. Check the client's status every hour. C. Document the client's behavior leading to the initiation of the restraints. D. Obtain written consent by the client for the placement of the restraints.

Correct Answer is C

Explanation

Document the client's behavior leading to the initiation of the restraints: Accurate and comprehensive documentation is essential in the client's medical record. This includes documenting the client's behavior or actions that necessitated the use of restraints. It is important to document the reason, duration, and type of restraint used.

Release the client's restraints every 2 hours or as per institutional policy: It is important to periodically release the restraints to assess the client's circulation, skin integrity, and overall well-being. Restraints should never be kept on continuously without intermittent release. Check the client's status every 15 minutes: The nurse should closely monitor the client's vital signs, level of comfort, and any signs of distress or complications. Frequent assessment ensures early identification and intervention if any issues arise.

Obtain informed consent: While obtaining consent is necessary for many procedures or treatments, including the use of restraints, it is not applicable in situations where there is an imminent risk of harm to the client or others. The use of restraints in mental health units is based on legal and ethical guidelines, prioritizing the client's safety and the safety of others.

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A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with postmortem care for a client who was a devout follower of Islam. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

Correct Answer is C

Explanation

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