When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Not allowing the client to interact with other clients

Checking on the client every 4 hours

Setting clear boundaries and making sure the client abides by them

Providing a safe environment by removing items that could cause harm

Answer and Explanation

The Correct Answer is D

A.   While isolation may be necessary in certain situations to ensure safety, it is not the most critical
intervention. It’s essential to balance safety with providing the client with support and not making them feel isolated or abandoned. The primary focus should be on creating a safe environment and addressing the immediate risk of self-harm.
B.   Checking on the client every 4 hours may not be frequent enough for a client who is at risk of self- harm or suicide. More frequent monitoring is typically required, especially if the client is deemed at high risk. Immediate and continuous observation is often necessary to prevent further attempts.
C.   While setting boundaries is important for therapeutic interactions, it is secondary to addressing immediate safety concerns. The primary focus should be on preventing self-harm and ensuring a safe environment rather than just enforcing rules.
D.   Providing a safe environment by removing items that could cause harm is the most crucial intervention for a client who has attempted suicide. This step directly addresses the risk of self-harm and helps prevent further suicide attempts. Creating a safe environment is a fundamental aspect of suicide prevention and immediate care.

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Correct Answer is B

Explanation

A. The sternoclavicular joint is where the sternum (breastbone) meets the clavicle (collarbone). It plays a role in the movement of the shoulder girdle but does not involve the jaw. Issues with this joint would typically present as shoulder or chest discomfort rather than problems with the jaw.
B. The temporomandibular joint is the joint where the mandible (lower jaw) meets the temporal bone of the skull, just in front of the ear. It is crucial for jaw movement, including opening, closing, and chewing. If a client feels that their jaws are "stuck," it is likely related to a problem with the TMJ. Common issues include TMJ disorders, which can cause pain, limited movement, or a sensation of the jaw being stuck.
C. The subtalar joint is located in the ankle, between the talus and calcaneus bones. It is involved in the movement of the foot, particularly in inversion and eversion. This joint is unrelated to jaw function, so problems here would affect the foot rather than the jaw.
D. The radioulnar joints are located in the forearm and involve the radius and ulna bones. These joints are responsible for the rotation of the forearm, such as turning the palm up or down. They do not relate to jaw movement or problems, so issues with these joints would affect the forearm or wrist rather than the jaw.

A. 2+ B. 3+ C. 1+ D. 4+

Correct Answer is B

Explanation

A. A reflex grade of 2+ is considered normal. It indicates that the reflex is present and of normal intensity, with a typical response.
B. A reflex grade of 3+ is considered brisk. It indicates that the reflex is more pronounced than normal
but not necessarily pathological. It’s often described as "brisk" or "exaggerated."
C. A reflex grade of 1+ is considered diminished or hypoactive. It indicates that the reflex is present but less intense than normal.
D. A reflex grade of 4+ is considered very brisk or hyperactive. It indicates a reflex response that is exaggerated and may suggest an upper motor neuron lesion or other neurological abnormalities.

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When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client presents to the nurse stating that his jaws feel "stuck". What joint should the nurse assess?

Correct Answer is B

Explanation

The nurse assesses brisk reflexes in a client. The nurse would document this finding as which of the following?

Correct Answer is B

Explanation

After a physical assessment, the nurse determines that a client has full range of motion of the temporomandibular joint. Which of the following assessments did the nurse complete with the client? Select all that apply.

Taste in the 1/3 posterior of your tongue is given by:

A patient is able to move both upper arms as follows: active movement against gravity, and some resistance. The nurse should document the muscle strength of the upper arms as:

The nurse places a coin in the patient's hand, the patient is with eyes closed. The ability to identify an object by feeling it is defined as:

When implementing nursing interventions for a client who has attempted suicide, which of the following is most important?

A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

Which of the following tests would be most appropriate for the nurse to use when assessing motor function of the trigeminal nerve?

During an assessment of the cranial nerves, a client reports spontaneously losing balance. The nurse should focus additional assessment on which cranial nerve?