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 D
Explanation
Choice A rationale:
A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence
Choice B rationale:
Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.
Choice C rationale:
An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.
Choice D rationale:
A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.
Correct Answer is ["A","C","D","E"]
Explanation
Choice A rationale:
Agitation is a common manifestation of delirium, as the client experiences a disturbance in attention, awareness, and cognition. The client may become restless, irritable, or aggressive due to the altered mental state.
Choice B rationale:
Slow, flat speech is not a manifestation of delirium, but rather a sign of depression or dementia. Clients with delirium may have rapid, incoherent, or slurred speech, depending on the cause and severity of the condition.
Choice C rationale:
Visual hallucinations are another manifestation of delirium, as the client may perceive things that are not there or misinterpret sensory stimuli. The client may also have auditory or tactile hallucinations, which can contribute to the agitation and confusion.
Choice D rationale:
Confusion is a hallmark manifestation of delirium, as the client has difficulty with orientation, memory, and reasoning. The client may not recognize familiar people or places, or may have fluctuating levels of consciousness. The confusion may worsen at night or in low-light settings, which is known as sundowning syndrome.
Choice E rationale:
Rapid mood swings are also a manifestation of delirium, as the client may exhibit emotional lability, anxiety, depression, fear, or anger. The mood changes may be unpredictable and inappropriate to the situation.
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