A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

"What coping methods help you when you feel bad?"

"Do you have thoughts of suicide?"

"Tell me why you hurt yourself."

"Who can we call to support you?"

Answer and Explanation

The Correct Answer is B

Rationale:

A. "What coping methods help you when you feel bad?": While assessing coping mechanisms is important for long-term care planning, it does not immediately address the client's current risk for self-harm or suicide. This question is more appropriate after ensuring the client's safety.

B. "Do you have thoughts of suicide?": Determining if the client has suicidal ideation is the priority in this situation. Clients who self-harm may be at high risk for suicide, and direct questioning helps assess intent, plan, and urgency, which is crucial for ensuring immediate safety.

C. "Tell me why you hurt yourself.": Exploring the reasons behind self-injury can be valuable later during therapy or assessment, but it is not the first priority. The nurse must first evaluate the client’s current mental state and risk for further harm before exploring motives.

D. "Who can we call to support you?": Identifying a support system is important for discharge planning and ongoing therapy, but it does not address the immediate concern of suicide risk. Ensuring the client's current safety takes precedence over external support at the time of admission.

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Correct Answer is C

Explanation

Rationale:

A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.

B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.

C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.

D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.

A. "I will position my arms away from my body when pushing an object." B. "I will position my body to face an object, so I avoid twisting C. "I will position my legs close together before lifting." D. "I will position objects away from my body before lifting them."

Correct Answer is B

Explanation

Rationale:

A. "I will position my arms away from my body when pushing an object.": Keeping the arms close to the body provides better leverage and reduces strain on the muscles and joints. Extending arms away increases risk of injury.

B. "I will position my body to face an object, so I avoid twisting: Facing the object directly helps maintain proper spinal alignment and reduces the risk of back injury by minimizing twisting motions during lifting or pushing.

C. "I will position my legs close together before lifting.": Keeping legs close together decreases stability and increases risk of losing balance. A wider stance improves balance and distributes weight evenly during lifting.

D. "I will position objects away from my body before lifting them.": Objects should be held close to the body to reduce strain on the back and arms. Holding objects away increases lever arm forces and injury risk.

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A nurse in a psychiatric unit is admitting a client who has self-inflicted cuts on their forearms. Which of the following is a priority response by the nurse?

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