A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?
Initiate one-to-one nursing observation.
Make a contract with the client for weight gain.
Administer the Hamilton depression scale.
Review the client's toxicology laboratory report.
The Correct Answer is A
initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.
Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.
Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.
Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.
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Correct Answer is D
Explanation
A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.
Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.
Correct Answer is B
Explanation
When a client is experiencing alcohol withdrawal, seizures are a common finding. Benzodiazepines are the preferred medications for alcohol withdrawal, and they are used to prevent seizures and treat symptoms of anxiety, agitation, and autonomic hyperactivity. Stuporous level of consciousness (Choice A), pathological changes on a CT scan (Choice C), and bradycardia (Choice D) are unlikely findings in a client experiencing alcohol withdrawal. Stuporous level of consciousness is more indicative of acute brain dysfunction or coma. CT scan findings may indicate structural brain injury, such as a brain tumor or stroke. Bradycardia is not a common finding in alcohol withdrawal but may occur in severe cases. However, tachycardia is a more common finding.
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