A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Isolate the client from all stressful situations that may precipitate a suicide attempt.

Have a one-to-one sitter for outpatient use.

Identify community resources for the client to use in a crisis.

Educate the family about providing a safe and structured environment for the client.

Assist the client to develop more effective coping mechanisms.

Answer and Explanation

Correct Answer : C,D,E

C. Identifying community resources is essential as it provides the client with accessible support during crises.
D. Educating the family about creating a safe and structured environment is also important because it involves the client's support system in their care, which can help prevent future crises.
E. Assisting the client in developing more effective coping mechanisms is vital for long-term management and recovery, as it empowers the client to handle stressors more healthily.
A. Isolating the client from all stressful situations is not practical or beneficial as it does not teach coping mechanisms or resilience.
B. Having a one-to-one sitter might be necessary in some inpatient settings but is not feasible or indicated for outpatient care.

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Correct Answer is B

Explanation

B. Naloxone administration can rapidly reverse the effects of opioids, potentially leading to the rapid onset of opioid withdrawal symptoms, which may include respiratory depression. Therefore, close monitoring of the client's airway, respiratory rate, oxygen saturation, blood pressure, and heart rate is critical to ensure their safety and stability.
A. Assessing and managing the client's gastrointestinal status may be necessary depending on the clinical situation but it is not the most urgent concern immediately following naloxone administration.
C. Assessing urinary output and ensuring adequate fluid balance is important. However, it is not the highest priority immediately after naloxone administration.
D. Hyperpyrexia, or extremely high fever, is not a common immediate concern following naloxone administration.

A. Refrains from manipulative behaviors B. Redirection of violent behaviors C. Withdraws when frustrated D. Participation in play activities

Correct Answer is D

Explanation

D. Engaging in play activities can indicate that the child is focusing their energy positively and is able to engage with their environment in a constructive way. Play can also serve as a therapeutic tool that helps children with ADHD improve their attention, reduce hyperactive behavior, and learn social skills.
A. Manipulative behaviors may not be directly related to the core symptoms of ADHD, but they can be present in some children with ADHD as a way of coping with difficulties in attention and impulse control.
B. Redirection of violent behaviors involves guiding the child towards more appropriate and non-violent ways of expressing their emotions and frustrations. Monitoring for successful redirection of violent behaviors would indicate progress in improving impulse control and emotional regulation.
C. Withdrawal when frustrated is not a desired outcome for a child with ADHD. Instead, the goal is typically to help the child develop coping strategies to manage frustration constructively and remain engaged in activities.

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A client with a history of a suicide attempt has been discharged and is being followed in an outpatient clinic. What is/are the most appropriate nursing intervention(s)? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who just received naloxone. Which nursing intervention is highest priority?

Correct Answer is B

Explanation

A 7-year-old with Attention Deficit-Hyperactivity Disorder (ADHD) evaluated at the mental health clinic is exhibiting hyperactivity and distractibility. The nurse should monitor for which desired outcome?

Correct Answer is D

Explanation

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