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 A

Explanation

A. This maneuver is intended to engage other muscle groups and increase overall muscle tone. It can help facilitate the patellar reflex by increasing muscle tension and sensitivity. This technique can enhance the reflex response by engaging the client in a physical action that might make the reflex more pronounced.
B. Squeezing the thigh might create discomfort or involuntary muscle contraction, which could interfere with the reflex response. It is not a recommended technique for eliciting the patellar reflex and may not have a significant effect on reflex assessment.
C. Stretching the arms over the head does not directly influence the patellar reflex. Reflexes are typically assessed in a relaxed state, and this action might not be relevant for improving the patellar reflex response.
D. Clenching the jaw might increase overall muscle tone temporarily, but it does not directly impact the patellar reflex. This technique is less likely to influence the patellar reflex compared to techniques that engage lower body muscle groups.

A. Kernig sign B. Arm Weakness C. Sudden confusion or trouble understanding D. Face Drooping E. negative Babinski reflex F. Speech Difficulty

Correct Answer is ["B","C","D"]

Explanation

A. The Kernig sign is a clinical test used to diagnose meningitis, not stroke. It involves flexing the patient’s hip and knee and then attempting to extend the knee while the hip is flexed. Pain or resistance during this maneuver can suggest meningeal irritation.
B. Arm weakness refers to the loss of strength or control in one or both arms, which can be a sign of a stroke. It may be noticeable when a person is unable to lift their arm or keep it raised.
C. Sudden confusion, trouble understanding, or difficulty speaking can be signs of a stroke. This may involve problems with language or comprehension, which are related to the areas of the brain responsible for these functions.
D. Face drooping, especially on one side of the face, is a classic sign of stroke. It occurs when the muscles on one side of the face weaken or become paralyzed.
E. The Babinski reflex is a test where the sole of the foot is stroked, and the normal response in adults is the downward flexion of the toes. An abnormal Babinski reflex (upward extension of the big toe) can indicate neurological problems but is not a specific warning sign of stroke.
F. Speech difficulty, such as slurred speech or trouble finding words, is a common sign of a stroke. It can involve problems with articulation, coherence, or understanding language.

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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

A nurse is having difficulty eliciting a patellar reflex. Which of the following would be most appropriate for the nurse to have the client do?

Correct Answer is A

Explanation

Stroke Warning signs includes? Select all that applied.

Correct Answer is ["B","C","D"]

Explanation

In the Neuro ICU (intensive care unit) while performing a neurological assessment of the patient the nurse noticed the patient: patient opens eyes, looks at you, responds slowly, and is somewhat confused. What level of consciousness (LOC) is this patient presenting?

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