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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Related Questions
Correct Answer is C
Explanation
A. While this is positive reinforcement, it doesn't directly address the client's expression of gratitude. It's important to acknowledge the client's feelings first.
B. This response avoids the client's expression of gratitude and shifts the focus to the nurse.
C. This response acknowledges the client's expression of gratitude and opens up a dialogue about their feelings about discharge. It allows the nurse to provide support and address any concerns the client might have.
D. This response assumes the client's feelings and doesn't allow for the expression of other emotions. The client might not be excited about discharge for various reasons.
Correct Answer is B
Explanation
A. Dementia is not typically caused by sudden environmental changes. Instead, it is a chronic condition that develops gradually over time due to neurodegenerative diseases, such as Alzheimer's disease, vascular dementia, or Lewy body dementia.
B. Dementia is characterized by a gradual decline in cognitive function, including memory, thinking, and reasoning skills. The progression of dementia is typically slow and leads to worsening symptoms over time. Currently, most types of dementia are considered irreversible, meaning that the damage to the brain is not reversible and the condition will continue to progress.
C. Dementia is a progressive condition that develops gradually, often over months or years. It is not characterized by a sudden onset. Sudden onset of cognitive symptoms is more indicative of delirium, which can be caused by acute medical conditions or other factors.
D. Dementia generally does not involve an altered level of consciousness. Instead, it primarily affects cognitive functions such as memory, reasoning, and orientation while consciousness remains clear.
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