A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.

Assign a staff member to stay with the client at all times.

Lock the doors to the unit and secure windows so they cannot be opened.

Remove any objects from the client's environment that could be used for self-harm.

Provide the client with plastic eating utensils for meals.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Assigning a staff member to stay with the client at all times is the priority action when a client declines to make a safety contract. This is because the immediate safety of the client is the primary concern in such situations.
Choice B rationale:
Locking the doors to the unit and securing windows so they cannot be opened might be considered a safety measure, but it is not the priority. The focus should be on direct supervision to ensure safety.
Choice C rationale:
Removing any objects from the client’s environment that could be used for self-harm is important, but it is not the priority. The immediate safety of the client through constant supervision is the priority.
Choice D rationale:
Providing the client with plastic eating utensils for meals is a safety measure, but it is not the priority. The immediate safety of the client through constant supervision is the priority.

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Correct Answer is D

Explanation

Choice A rationale:

A BUN of 22 mg/dL is slightly elevated but not a contraindication for clozapine.

Choice B rationale:

A serum potassium of 3.3 mEq/L is slightly low but not a contraindication for clozapine.

Choice C rationale:

A hematocrit of 55% is high but not a contraindication for clozapine.

Choice D rationale:

A WBC of 2,900 cells/mm² is low and can indicate agranulocytosis, a potentially life-threatening condition. Clozapine should be discontinued.

A. "Increased flatulence is an indication of toxicity.”. B. "Vomiting is an indication of toxicity.”. C. "I will report any loss of appetite.”. D. "I will call my provider if I experience any headaches.”.

Correct Answer is B

Explanation

Choice A rationale:
Increased flatulence is not typically associated with lithium toxicity.
Choice B rationale:
Vomiting is a common symptom of lithium toxicity, indicating the client understands the teaching.
Choice C rationale:
While loss of appetite can occur in various conditions, it’s not a specific indicator of lithium toxicity.
Choice D rationale:
Headaches can be caused by various factors and are not specifically associated with lithium toxicity.

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A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing abnormal laboratory values for four clients who have schizophrenia and take clozapine. For which of the following clients should the nurse withhold the medication and notify the provider immediately to have clozapine therapy discontinued?

Correct Answer is D

Explanation

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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A nurse is teaching a client who has bipolar disorder about lithium. Which of the following statements should the nurse include in the teaching?.

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and ataxia. Which of the following actions should the nurse take?

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A nurse asks a client who is suicidal to make a safety contract, but the client declines.

Which of the following actions should the nurse identify as the priority?.