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 ["A","C","E"]
Explanation
A. Providing companionship can help reduce feelings of isolation and agitation that may be exacerbated by sundown syndrome. Presence and interaction with a supportive person can provide comfort, reassurance, and a sense of security, which may help manage anxiety and agitation during the late hours.
B. Engaging in stimulating activities in the late afternoon or evening can sometimes worsen symptoms of sundown syndrome. Instead, activities should be calming and relaxing as excessive stimulation can
increase agitation and confusion. It’s better to plan stimulating activities earlier in the day.
C. Maintaining a familiar routine helps provide structure and predictability, which can be comforting for individuals with dementia. Consistent routines can help reduce confusion and anxiety, especially during the times when sundown syndrome symptoms are most pronounced.
D. While reminding the client about bedtime may seem like a good strategy, it can sometimes lead to frustration or increased agitation if the client is not ready for sleep or is confused. It is generally more effective to create a calming environment and use soothing routines rather than directly reminding the client of bedtime.
E. Reducing environmental stimulation, such as minimizing noise, bright lights, and other distractions, can help create a calm and peaceful environment. This approach can help prevent overstimulation, which is known to exacerbate sundown syndrome symptoms.
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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