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.

Answer and Explanation

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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Correct Answer is C

Explanation

The correct answer is C. Place a pillow under the child's head.

Rationale: The nurse should protect the child from injury by helping them to the floor and clearing away furniture or other items. The nurse should also place a pillow under the child's head to prevent head trauma and turn them onto their side to prevent aspiration of saliva or vomit. The nurse should not put anything in the child's mouth, as this could cause choking or damage to the teeth or tongue. The nurse should also not turn the child onto their back, as this could compromise their airway. The nurse should not restrain the child's upper extremities, as this could increase muscle spasms and cause injury.

A. Arch B. Drooling C. Fever D. Steatorrhea E. Tinnitus

Correct Answer is C

Explanation

Choice A reason:

Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.

Choice B reason:

Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.

Choice C reason:

Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.

Choice D reason:

Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.

Choice E reason:

Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.

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