After establishing a no-harm contract with the client, the nurse should:
continue to maintain close observation.
begin treatment with antidepressants.
begin to assess client risk factors.
decrease observation activity to allow client autonomy.
The Correct Answer is A
A. A no-harm contract is a useful tool. However, it's essential to remember that it's not a guarantee against self-harm. Close observation remains crucial, as suicidal ideation can fluctuate.
B. Antidepressants can be part of the treatment plan but they are not an immediate solution and require careful monitoring. The priority is ensuring the client's safety.
C. This assessment should have already been conducted before establishing the no-harm contract. Ongoing assessment is important, but immediate observation takes precedence.
D. Reducing observation could put the client at risk. Continuous monitoring is necessary to prevent self- harm.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Patients on lithium do not need to avoid aged cheese and red wine specifically. The main dietary advice is to avoid significant changes in salt intake rather than specific foods like aged cheese or red wine.
B. Skin eruptions are not a common concern specifically linked to lithium therapy. While monitoring for side effects is important, skin changes are not typically a primary focus in lithium management.
C. Lithium use is not directly associated with routine blood pressure monitoring unless there is a specific concern about blood pressure or other cardiovascular issues. While monitoring blood pressure is important for overall health, it is not a specific requirement for patients on lithium unless there are other related concerns.
D. Monitoring blood levels of lithium is essential for managing the risk of toxicity and ensuring therapeutic efficacy. Lithium has a narrow therapeutic range, and regular blood tests are necessary to adjust dosages and avoid side effects.
Correct Answer is B
Explanation
A. This principle relates to protecting patient information. It is not relevant to this scenario.
B. This principle respects the patient's right to self-determination. By disregarding the client's preference for walking with her daughter, the nursing assistant violated the client's autonomy.
C. This principle involves doing good for the patient. While the nursing assistant might have intended to benefit the client by encouraging exercise, it was done at the expense of the client's autonomy.
D. This principle involves avoiding harm to the patient. While the client was upset, there is no evidence of physical harm in this situation.
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