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
The correct answer is choice d. Measure the client’s abdominal girth daily.
Choice A rationale:
Positioning the client supine with legs elevated is not recommended for managing ascites. This position does not help in reducing fluid accumulation in the abdomen and may worsen respiratory issues.
Choice B rationale:
Keeping the client’s daily protein intake below 0.8 g/kg is not typically recommended for clients with cirrhosis and ascites. Adequate protein intake is necessary to prevent muscle wasting and maintain nutritional status.
Choice C rationale:
Restricting the client’s sodium intake to 2 g not 3g per day is a common intervention for managing ascites, but it is usually more restrictive, often around 2 g per day, to effectively reduce fluid retention.
Choice D rationale:
Measuring the client’s abdominal girth daily is essential for monitoring the progression of ascites. It helps in assessing the effectiveness of treatment and detecting any worsening of the condition.
Correct Answer is B
Explanation
The correct answer is choiceb. Place the client in Trendelenburg position.
Choice A rationale:
Loosely wrapping the cord with petroleum gauze is not recommended.Instead, the cord should be wrapped with sterile saline-soaked gauze to prevent it from drying out and to minimize infection risk.
Choice B rationale:
Placing the client in Trendelenburg position helps to relieve pressure on the prolapsed cord by using gravity to shift the fetus away from the pelvis. This position helps to improve blood flow through the umbilical cord until delivery can be arranged.
Choice C rationale:
Evaluating uterine tone is not directly related to managing a prolapsed umbilical cord.The priority is to relieve pressure on the cord to prevent fetal hypoxia.
Choice D rationale:
Applying fundal pressure is contraindicated as it can increase pressure on the prolapsed cord, worsening the situation.
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