A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

Ensure the client swallows each dose of medication.

Limit the personal toiletries in the client's room to cologne.

Observe the client's behavior every 2 hr.

Keep the client's door shut when they are in the room.

Answer and Explanation

The Correct Answer is A

Rationale:

A. Ensure the client swallows each dose of medication: Clients with recent suicide attempts are at risk for hoarding medications to use in a future overdose. The nurse should closely monitor medication administration and confirm that each dose is swallowed to ensure safety.

B. Limit the personal toiletries in the client's room to cologne: Cologne often contains alcohol and could be misused for ingestion or fire-related self-harm. It should not be permitted. All personal items should be carefully screened to eliminate potential hazards.

C. Observe the client's behavior every 2 hr: Monitoring every 2 hours is insufficient for a client at high risk of suicide. More frequent or continuous observation (such as 1:1 supervision) is typically warranted during the acute phase to ensure immediate safety.

D. Keep the client's door shut when they are in the room: Keeping the door closed limits visibility and increases the risk of the client engaging in self-harm without detection. The door should remain open or observation should be maintained to ensure the client’s ongoing safety.

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Correct Answer is B

Explanation

Rationale:

A. "I will position my arms away from my body when pushing an object.": Keeping the arms close to the body provides better leverage and reduces strain on the muscles and joints. Extending arms away increases risk of injury.

B. "I will position my body to face an object, so I avoid twisting: Facing the object directly helps maintain proper spinal alignment and reduces the risk of back injury by minimizing twisting motions during lifting or pushing.

C. "I will position my legs close together before lifting.": Keeping legs close together decreases stability and increases risk of losing balance. A wider stance improves balance and distributes weight evenly during lifting.

D. "I will position objects away from my body before lifting them.": Objects should be held close to the body to reduce strain on the back and arms. Holding objects away increases lever arm forces and injury risk.

A. Positions the client in a chair before applying the stockings B. Elevates the legs before applying the stockings C. Rolls the extra stocking material down to the client's knee D. Massages the legs before applying the stockings

Correct Answer is B

Explanation

Rationale:

A. Positions the client in a chair before applying the stockings: Applying antiembolic stockings while the client is in a seated position may lead to venous pooling in the lower extremities. This reduces the effectiveness of the stockings and may cause improper fit or increased pressure in dependent areas.

B. Elevates the legs before applying the stockings: Elevating the legs allows venous blood to drain from the lower extremities, reducing swelling and promoting proper application of the stockings. This ensures the stockings provide even compression and help prevent complications like thrombus formation.

C. Rolls the extra stocking material down to the client's knee: Rolling down the stockings creates a tourniquet effect, which can impair circulation and increase the risk of complications like venous stasis or skin breakdown. Stockings should be smooth and free of folds.

D. Massages the legs before applying the stockings: Massaging the legs, especially in a client with phlebitis, may dislodge a clot if present and increase the risk of embolism. Gentle handling without vigorous massage is essential in clients at risk for thromboembolic events.

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A nurse is planning care for a client who recently attempted suicide. Which of the following actions should the nurse plan to take?

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Naxlex Comprehensive Predictor Exams

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