A nurse on a mental health unit is admitting a client following a suicide attempt. Which of the following actions is the nurse's priority?
Establish a therapeutic relationship with the client.
Instruct the client on stress management techniques.
Have the client sign a no-suicide contract.
Maintain constant observation of the client.
The Correct Answer is D
Choice A rationale:
Establishing a therapeutic relationship is important, but the immediate priority is to ensure the safety of the client by maintaining constant observation.
Choice B rationale:
Instructing the client on stress management techniques is important, but safety comes first.
Choice C rationale:
Having the client sign a no-suicide contract may provide some reassurance, but it is not a substitute for constant observation.
Choice D rationale:
Maintaining constant observation of the client is the priority to prevent any further self-harm or suicide attempts.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A slightly elevated WBC count is not a contraindication for the administration of methylergonovine.
Choice B rationale:
Methylergonovine can cause vasoconstriction and bronchoconstriction, which can exacerbate asthma symptoms. Therefore, a history of asthma is a contraindication for its use.
Choice C rationale:
Hgb of 11.2 g/dL is within an acceptable range and not a contraindication for methylergonovine.
Choice D rationale:
Blood pressure of 154/98 mm Hg is elevated, but it is not a contraindication for the administration of methylergonovine.
Correct Answer is C
Explanation
Choice A rationale:
Newborns typically lose some weight after birth, but 15 percent loss would be excessive and concerning. A normal weight loss range is about 5 to 10 percent.
Choice B rationale:
Newborns should be fed on demand rather than adhering to strict schedules to ensure they are adequately nourished.
Choice C rationale:
Breastfeeding requires additional energy, and mothers are generally advised to consume around 500 extra calories a day to support milk production and their own energy needs.
Choice D rationale:
Offering a pacifier before sleep can reduce the risk of sudden infant death syndrome (SIDS), but this recommendation usually starts at around 1 to 2 months of age.
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