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 C

Explanation

Choice A rationale:

A lithium level of 1.8 mEq/L is above the therapeutic level for initial treatment (0.8 to 1.4 mEq/L)3.

Choice B rationale:

A lithium level of 1.8 mEq/L is above, not below, the therapeutic treatment level.

Choice C rationale:

A lithium level of 1.8 mEq/L is at the toxic level. A blood lithium level greater than 1.5 mEq/L indicates toxicity.

Choice D rationale:

A lithium level of 1.8 mEq/L is not within the maintenance treatment level (0.4 to 1.3 mEq/L)3.

A. The client has a history of bulimia nervosa. B. The client has a parent who has dependent personality disorder. C. The client has borderline personality disorder. D. The client recently received a promotion at work.

Correct Answer is C

Explanation

Choice A rationale:

While bulimia nervosa can be associated with self-harm behaviors, it is not as strongly linked as borderline personality disorder.

Choice B rationale:

Having a parent with dependent personality disorder is not a specific risk factor for self-harm behaviors.

Choice C rationale:

Borderline personality disorder is strongly associated with self-harm behaviors.

Choice D rationale:

Receiving a promotion at work is generally considered a positive event and is not typically associated with an increased risk of self-harm behaviors.

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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 reviews the laboratory report for a client who is receiving lithium three times daily PO. The client's current blood lithium level is 1.8 mEq/L. The nurse identifies that this lab value indicates which of the following?.

Correct Answer is C

Explanation

A nurse is reviewing the medical record of a client who performs self-injury. Which of the following information should the nurse identify as placing the client at risk for self-harm behaviors?

Correct Answer is C

Explanation

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A nurse is caring for a client who is experiencing suicidal thoughts. Which of the following actions should the nurse take?.

A nurse is caring for a client who has been diagnosed with schizophrenia. The client has been wearing the same clothes for the past week and appears unkempt and unbathed. Which of the following statements should the nurse make to the client?

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?.