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?"
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. A client who has a firm fundus following a vaginal birth and reports continuous perineal pain of 8 on a scale of 0 to 10: Although the fundus is firm, severe continuous perineal pain may indicate complications such as hematoma or infection, requiring immediate assessment and intervention to prevent worsening condition.
B. A client who is 30 hr postpartum and reports feeling tearful and overwhelmed: Postpartum emotional lability is common in this timeframe and generally not an immediate safety concern. The nurse should provide support but this client’s condition is not urgent.
C. A client who is 12 hr postpartum and reports having to urinate frequently: Frequent urination postpartum may be due to diuresis or normal bladder function return and is not typically urgent unless accompanied by other signs of infection or retention.
D. A client who had a cesarean birth yesterday and reports burning incision pain of 5 on a scale of 0 to 10: Moderate incision pain is expected after surgery and can be managed with analgesics; it does not require immediate intervention compared to potential perineal complications.
Correct Answer is B
Explanation
Rationale:
A. Valerian root: Valerian root is primarily used for its sedative properties and is commonly recommended for sleep disorders or anxiety. It does not have evidence-based benefits for lowering cholesterol levels and is not appropriate for this client's condition.
B. Garlic: Garlic has been shown in some studies to modestly reduce total cholesterol and low-density lipoprotein (LDL) levels. It may also have antiplatelet effects, making it a relevant herbal supplement for clients with elevated cholesterol when used appropriately.
C. Aloe: Aloe is typically used topically for wound healing or orally for constipation. It is not known to have any significant effect on lipid levels and is not recommended for cholesterol management.
D. Saw palmetto: Saw palmetto is most commonly used for benign prostatic hyperplasia (BPH) symptoms in men. It has no known lipid-lowering effects and is not suitable for managing high cholesterol.
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