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

Explanation

Rationale:

A. Remove the client's dentures from their mouth before rigor mortis begins: Removing dentures is generally done after rigor mortis to maintain the natural appearance of the face for viewing. Premature removal can alter facial structure and affect family perceptions.

B. Turn on all the lights in the room before the family views the client's body: Bright lighting may be uncomfortable or overwhelming for grieving family members. Soft, gentle lighting is usually preferred to create a calm and respectful environment.

C. Ask the client's family about cultural or religious practices regarding postmortem care: Different cultures and religions have specific rituals and practices for caring for the deceased. Inquiring about these preferences ensures that the nurse respects the family’s beliefs and supports culturally sensitive care.

D. Position the client's bed flat without a pillow under their head: After death, the head of the bed should be slightly elevated (e.g., 15-30 degrees) to prevent blood from pooling in the face and causing discoloration, which can be distressing for the family.

A. Thoroughly explain each procedure to the toddler. B. Allow the toddler to handle the equipment. C. Completely undress the toddler. D. Start the examination with routine immunizations.

Correct Answer is B

Explanation

Rationale:

A. Thoroughly explain each procedure to the toddler: Toddlers have limited cognitive ability to understand detailed explanations. Overexplaining may cause anxiety rather than reassurance, especially if unfamiliar medical terms are used.

B. Allow the toddler to handle the equipment: Allowing the toddler to touch and explore safe medical equipment, like a stethoscope, helps reduce fear and builds trust. This play-based approach fosters cooperation and makes the exam less intimidating.

C. Completely undress the toddler: Toddlers can feel vulnerable when fully undressed. It is more appropriate to remove clothing gradually, only as needed for each part of the examination, to ensure comfort and security.

D. Start the examination with routine immunizations: Beginning with painful procedures like injections can create fear and resistance, making the rest of the exam more difficult. Immunizations should be done at the end of the visit.

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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

A nurse is providing postmortem care to a client who just died. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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