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 D

Explanation

Rationale:

A. Ask the client's partner to sign as next of kin: The partner cannot legally provide informed consent on behalf of the client unless they have legal power of attorney. Consent must come from the client unless they are incapacitated.

B. Document the client's refusal in their medical record: While documentation is important, it should only occur after ensuring the client fully understands the procedure. Without effective communication, refusal may not be informed.

C. Check to see if the client has an advance directive: Advance directives guide care if the client is incapacitated but may not apply if the client is alert and able to make decisions about the current procedure.

D. Ask the provider to explain the procedure through an interpreter: Using a professional interpreter ensures clear communication so the client can make an informed decision about the cesarean birth, respecting autonomy and reducing misunderstanding.

A. "You should appoint a family member as your health care surrogate." B. "Once you have completed a living will, it cannot be changed." C. "You will need an attorney to appoint a health care surrogate." D. "Your health care surrogate will make decisions on your behalf if you are unable."

Correct Answer is D

Explanation

Rationale:

A. "You should appoint a family member as your health care surrogate.": While clients may choose a family member, they are not required to do so. The decision is personal, and clients can appoint anyone they trust, regardless of relation, to serve as their health care surrogate.

B. "Once you have completed a living will, it cannot be changed.": A living will can be revised or revoked at any time by the client as long as they remain mentally competent. Clients retain the right to alter their advance directives based on changes in preferences or health status.

C. "You will need an attorney to appoint a health care surrogate.": Appointing a health care surrogate does not require an attorney. Most states allow individuals to complete this process using standardized forms and witnesses, without the need for legal representation.

D. "Your health care surrogate will make decisions on your behalf if you are unable.": A health care surrogate is authorized to make medical decisions when the client is no longer capable of doing so. This ensures that the client’s preferences are respected even if they become incapacitated.

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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 speaking with the partner of a client who speaks a different language than the nurse. The partner tells the nurse that the client does not want to sign an informed consent for an urgent cesarean birth. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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