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's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.

Choice B rationale:

While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.

Choice C rationale:

The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.

Choice D rationale:

The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.

A. Cluster nursing care activities. B. Hyperoxygenate the client before suctioning. C. Keep the room well lit to orient the client. D. Maintain the client's PaCO2 at 50 mm Hg.

Correct Answer is A

Explanation

Choice A rationale:

Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.

Choice B rationale:

Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.

Choice C rationale:

Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.

Choice D rationale:

Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.

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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

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Correct Answer is A

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