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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The client is experiencing signs of an allergic reaction or anaphylaxis, which can be life-threatening. The rapid response team should be called to provide immediate medical assistance.

Choice B rationale:

Intubation is not the immediate priority. Addressing the allergic reaction and ensuring the client's airway, breathing, and circulation are the first steps.

Choice C rationale:

Obtaining an arterial blood gas (ABG) level is not the priority when the client is experiencing respiratory distress and facial swelling.

Choice D rationale:

Administering diphenhydramine may be part of the treatment plan, but the immediate priority is to call for emergency assistance to manage the allergic reaction.

A. "You should avoid temperature extremes." B. "You should engage in high-impact exercise twice per week." C. "You should drink at least 2 liters of fluids each day." D. "You should not receive the influenza vaccine."

Correct Answer is A

Explanation

Choice A rationale:

Avoiding temperature extremes can help prevent triggering a sickle cell crisis. Cold temperatures can cause blood vessels to constrict, leading to poor blood flow and increased risk of cell sickling.

Choice B rationale:

Engaging in high-impact exercise might not be recommended, as vigorous exercise can increase the risk of dehydration and oxygen deprivation, potentially triggering a crisis.

Choice C rationale:

Staying well-hydrated by drinking fluids is important, but temperature regulation is a key factor in preventing sickle cell crises.

Choice D rationale:

Receiving the influenza vaccine is recommended for individuals with sickle cell disease to reduce the risk of infections that could trigger a crisis. This statement is incorrect; the client should receive the influenza vaccine unless contraindicated.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving an initial dose of vancomycin IV. The client begins experiencing dyspnea and swelling of the face. After discontinuing the vancomycin infusion, which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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