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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is C
Explanation
Choice A rationale:
Taking lithium on an empty stomach is not necessary. Lithium can be taken with or without food.
Choice B rationale:
Excessive salivation is not a common side effect of lithium.
Choice C rationale:
Vomiting or diarrhea can lead to dehydration, which increases the risk of lithium toxicity by reducing the excretion of lithium. Therefore, it’s important to notify your provider if you experience these symptoms.
Choice D rationale:
Decreasing fluid intake can lead to dehydration and increase the risk of lithium toxicity. It’s recommended to maintain a normal fluid intake while taking lithium.
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