What is the priority finding to report to the provider for a client who has schizophrenia and is taking clozapine?

The correct answer is:

A. Implement continuous one-to-one observation.

Choice A reason:

Implementing continuous one-to-one observation is the most immediate and direct method to ensure the safety of a client who has been admitted after a suicide attempt. This involves assigning a staff member to stay with the client at all times, providing constant supervision to prevent self-harm. It is a standard safety measure in mental health facilities for clients at high risk of suicide.

Choice B reason:

While encouraging the client to participate in group therapy is a valuable part of the treatment plan, it is not the first action a nurse should take. Group therapy is beneficial for social support and developing coping strategies, but it is not an immediate safety measure for a client at risk of suicide.

Choice C reason:

Asking the client to sign a no-suicide contract can be part of the therapeutic process, but it is not the first step in acute care. These contracts involve the client agreeing not to harm themselves and to seek help if suicidal thoughts occur. However, they are not considered a substitute for active supervision and intervention.

Choice D reason:

Establishing a rapport to foster trust is crucial for effective nursing care and is an ongoing process. It helps in creating a therapeutic relationship, which is essential for the client's long-term recovery. However, it is not the immediate priority in a crisis situation where the client's safety is at risk.

A. Weigh the client every other day – Frequent weighing can increase the client’s focus on weight, potentially adding stress and anxiety, which is not beneficial for managing binge eating disorder.
B. Plan a menu with the client – Although planning meals can be helpful, remaining with the client after meals is more directly aimed at preventing bingeing behaviors.
C. Remain with the client for 1 hr after meals – Staying with the client after meals helps to monitor for any signs of binge eating behavior and provides support, reducing the likelihood of excessive eating episodes.
D. Offer snacks when the client is hungry – Unstructured snacking can promote impulsive eating and does not assist the client in establishing controlled eating patterns.