A nurse is reinforcing teaching with a newly licensed nurse regarding sources of medication information. Which of the following resources should the nurse include as reliable references for the nurse to use to evaluate medication information? (Select all that apply.)(Select All that Apply.)

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.

Explanation:

A. "Reliance on personal experiences is important to the process of EBP."

This statement is not accurate in the context of evidence-based practice (EBP). EBP emphasizes the use of the best available evidence from research, combined with clinical expertise and patient values and preferences. While personal experiences can provide context, they should not be the primary basis for decision-making in EBP.

B. "Identifying the problem is the first step of the EBP process."

This statement is correct. The first step in the EBP process is identifying a clinical problem or question that requires evidence-based intervention or decision-making. This step involves clearly defining the issue and understanding its significance.

C. "Reviewing the effectiveness of the findings is the last step of the EBP process."

This statement is not accurate. While evaluating the effectiveness of the chosen intervention or practice change is an essential component of EBP, it is not necessarily the last step. EBP involves an iterative process where findings are continuously evaluated, integrated into practice, and refined based on ongoing evidence and outcomes.

D. "There are four steps in the process of EBP."

This statement is not entirely accurate. While different models and frameworks may outline EBP in different steps or stages, it typically involves multiple steps that include formulating a clinical question, searching for evidence, critically appraising the evidence, applying the evidence to practice, and evaluating outcomes.