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 A

Explanation

Rationale:

A. Support the extremity above and below each joint during the exercises: Supporting the limb properly prevents strain on the joints and muscles, reduces pain, and helps maintain proper alignment during passive range-of-motion exercises.

B. Repeat each exercise movement 10 times: Repetitions vary depending on the client’s condition and tolerance. A general guideline is 5 to 10 repetitions, but individualized assessment is important to avoid fatigue or injury.

C. Move each joint just past the point of resistance: Moving a joint beyond the point of resistance can cause pain, injury, or dislocation. Movements should be gentle and stop when resistance or discomfort is felt.

D. Position the bed at mid-thigh level: Bed height should be adjusted for caregiver ergonomics to prevent injury, but "mid-thigh level" is not a standard recommendation for performing range-of-motion exercises.

A. Plan a time at the end of the shift to document nursing interventions. B. Delegate collection of vital signs to the assistive personnel on the team C. Make a priority to-do list at the beginning of the shift. D. Keep track of how long it takes to complete certain tasks E. Complete activities with one client before moving to another client.

Correct Answer is ["B","C","D"]

Explanation

Rationale:

A. Plan a time at the end of the shift to document nursing interventions: Delaying documentation until the end of the shift risks forgetting important details and compromises accuracy. Best practice is to document interventions and observations as close to the time of care as possible to ensure timely, complete records.

B. Delegate collection of vital signs to the assistive personnel on the team: Delegating routine tasks like vital sign collection allows the nurse to focus on complex responsibilities requiring clinical judgment. This supports time efficiency while ensuring client care needs are still met promptly.

C. Make a priority to-do list at the beginning of the shift: Creating a task list based on client acuity and scheduled interventions helps the nurse remain focused and organized. Prioritizing tasks early supports decision-making and improves workflow throughout the shift.

D. Keep track of how long it takes to complete certain tasks: Monitoring time spent on different tasks helps identify inefficiencies and allows the nurse to adjust workflow. This self-awareness supports better time management in future shifts.

E. Complete activities with one client before moving to another client: Focusing on one client at a time may lead to inefficiencies and delayed care for other clients. Nurses should cluster care and prioritize based on client needs, rather than adhering rigidly to completing all care for one client before moving on.

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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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