A nurse is assisting in the preparation of an in-service about evidence-based practice (EBP).

Which of the following questions should the nurse include when discussing critical appraisal of collected evidence?(Select All that Apply.)

Explanation:

A. Administer the Hamilton depression scale:

The Hamilton Depression Rating Scale is a tool used to assess the severity of depression symptoms in individuals. While assessing the client's depression level is an important aspect of mental health assessment, it is not the immediate priority in this scenario. The client has been admitted following a suicide attempt, indicating an acute risk to their safety. Therefore, the priority at this stage is to ensure the client's safety and prevent any further harm or attempts at self-harm.

B. Make a contract with the client for weight gain:

Making a contract with the client for weight gain, especially in the context of anorexia nervosa, may be an important aspect of the client's overall treatment plan. However, in this scenario, the client's immediate safety takes precedence. The client has a history of depression, substance abuse, and anorexia nervosa, and the primary concern at admission is to prevent any further self-harm or suicide attempts.

C. Review the client's toxicology laboratory report:

Reviewing the client's toxicology laboratory report is important for understanding any recent substance abuse and its potential impact on the client's physical and mental health. However, while this information is relevant to the client's overall care, it is not the first action to take upon admission. The immediate priority is to ensure the client's safety and provide appropriate monitoring and intervention to prevent further harm.

D. Initiate one-to-one nursing observation:

This is the correct answer. Initiating one-to-one nursing observation means assigning a dedicated nurse to continuously monitor and supervise the client closely. This level of observation is crucial in a situation where there is a history of suicide attempt and ongoing risk of self-harm. One-to-one observation allows for immediate intervention if the client shows signs of distress or attempts to harm themselves, ensuring their safety while they are in the acute mental health unit.

Explanation:

A. DNR:

DNR stands for "Do Not Resuscitate." It is a medical order that indicates a patient's preference not to receive cardiopulmonary resuscitation (CPR) in case of cardiac or respiratory arrest. This abbreviation is unrelated to medication administration instructions and does not indicate "to administer medications before meals."

B. ONG:

The abbreviation ONG is not commonly used in medical contexts to indicate medication administration instructions or timing. It does not specifically relate to the administration of medications before meals.

C. ac:

The abbreviation "ac" is derived from the Latin term "ante cibum," which translates to "before meals." In medical orders, "ac" is used to indicate that a medication should be taken or administered before meals. For example, "Take 1 tablet ac" means to take one tablet before meals.

D. Tx:

The abbreviation "Tx" is commonly used in medical contexts to denote treatment or therapy. However, it does not specifically indicate "to administer medications before meals." It is a broader term that can refer to various aspects of patient care and interventions.