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 C
Explanation
Choice A rationale:
Placing the newborn under a radiant warmer is not directly related to addressing breastfeeding-related jaundice.
Choice B rationale:
Supplementing breastfeeding with formula is not the first-line approach and may interfere with establishing successful breastfeeding.
Choice C rationale:
Breastfeeding-related jaundice can occur if the newborn is not effectively breastfeeding and not getting enough milk. Assessing the effectiveness of breastfeeding is important to address the underlying cause of jaundice.
Choice D rationale:
Administering Rho(D) immune globulin is unrelated to addressing jaundice in a breastfed newborn.
Correct Answer is C
Explanation
Choice A rationale:
Thawing frozen foods at room temperature can promote bacterial growth, increasing the risk of foodborne illness.
Choice B rationale:
There is no need for the client to reduce their intake of calcium-containing foods specifically to prevent foodborne illness. Calcium-containing foods are not associated with an increased risk of bacterial contamination.
Choice C rationale:
Cooking raw fish and steak to the well-done stage is recommended to kill harmful bacteria and reduce the risk of foodborne illness, which is particularly important for individuals with neutropenia who are more susceptible to infections.
Choice D rationale:
Cutting damaged areas from fruits and vegetables is a good practice to reduce the risk of contamination, but it does not address the risk of bacterial contamination from undercooked meat and fish.
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