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.
Keep the client's door shut when they are in the room.
Observe the client's behavior every 2 hr.
The Correct Answer is A
The correct answer is A.
Ensure the client swallows each dose of medication. A client who recently attempted suicide is at high risk of another suicide attempt and needs closemonitoring and supervision. The nurse should ensure that the client swallows each dose of medication to prevent hoarding or overdosing on pills. The nurse should also remove any potential means of self-harm from the client's room, such as sharp objects, belts, cords, or cologne that contains alcohol. The nurse should keep the client's door open or use a window to observe them at all times, not just every 2 hours.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Urine specific gravity should not be reported by the nurse. While urine specific gravity is an important indicator of hydration status and kidney function, the provided information does not suggest any abnormalities in urinary output or signs of kidney issues. It is not the most critical finding to report in this scenario.
Choice B reason:
Prealbumin should not be reported by the nurse. Prealbumin is a protein used to assess nutritional status, but its significance in this situation is not apparent from the provided data. It may be relevant in other contexts, such as assessing malnutrition, but it does not directly address the current findings.
Choice C reason:
Temperature should not be reported by the nurse. The provided information does not include any data about the client's temperature, and there are no signs of infection mentioned. While temperature is an important vital sign, it is not relevant to the findings presented in this scenario.
Choice D reason
The nurse should report the "hypoactive bowel sounds upon auscultation" to the provider. Hypoactive bowel sounds can be a sign of gastrointestinal (GI) motility issues, which may indicate a potential problem with the client's digestive system. It could be due to various causes such as bowel obstruction, inflammation, or other GI disorders. Reporting this finding to the provider is essential so that appropriate assessments and interventions can be taken to address the client's condition.
Correct Answer is C
Explanation
The correct answer is C. The risk manager.
Rationale: The risk manager is responsible for identifying and managing potential or actual sources of harm or loss in a healthcare organization. The risk manager would be interested in analyzing the data on zolpidem use and fall rate, implementing preventive measures, and reporting adverse events to regulatory agencies if needed. The surgeon may not be directly involved in prescribing zolpidem or monitoring its effects on postoperative clients. The case manager may not have access to or authority over medication administration policies or practices. The pharmacist may be able to provide information on zolpidem's pharmacokinetics and pharmacodynamics, but may not be able to address the organizational factors that contribute to fall risk.
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