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 ["C","D","E"]

Explanation

Rationale:

A. Reinforce client teaching about walking with crutches: Teaching or reinforcing client education is a nursing responsibility and should not be delegated to assistive personnel. It requires assessment, evaluation, and knowledge of the client's learning needs and physical limitations.

B. Plan care for a client who has dysphagia: Care planning involves critical thinking and individualized assessment, which fall under the registered nurse’s scope of practice. Dysphagia management also requires knowledge of aspiration risk and appropriate interventions.

C. Transfer a client who is receiving radiation therapy to radiology: Transferring stable clients to departments such as radiology is within the scope of assistive personnel, as long as the client does not require specialized monitoring or assessment during the transfer.

D. Record urine output for a client who has a suprapubic catheter: Measuring and documenting urinary output is a routine task that assistive personnel can perform. The catheter type does not affect the ability to carry out this basic observation.

E. Measure vital signs for a client who requires contact precautions: Assistive personnel are trained to take vital signs and follow isolation protocols. Measuring vital signs under contact precautions is appropriate as long as proper PPE and hygiene practices are followed.

A. "I should gain half of a pound per week to meet my treatment goal’ B. "The staff will watch me closely for 1 hour after each meal’ C. "The treatment goal is to be within 60 percent of my ideal body weight." D. "The staff will weigh me every night before I go to bed."

Correct Answer is B

Explanation

Rationale:

A. "I should gain half of a pound per week to meet my treatment goal": Weight gain goals for clients with anorexia nervosa are typically more aggressive, often around 1 to 3 pounds per week, to restore healthy weight timely and prevent complications of prolonged malnutrition.

B. "The staff will watch me closely for 1 hour after each meal": Monitoring clients after meals is essential to prevent purging behaviors, such as vomiting or excessive exercise. The one-hour observation period helps ensure safety and supports recovery.

C. "The treatment goal is to be within 60 percent of my ideal body weight.": Treatment aims to restore clients to at least 85 to 90 percent of their ideal body weight to improve physical and psychological health; 60 percent is dangerously low and not an appropriate goal.

D. "The staff will weigh me every night before I go to bed.": Weighing is typically done once in the morning before breakfast and after voiding, to ensure consistency and accuracy. Nighttime weighing is not standard practice and may contribute to anxiety.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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