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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
When collecting data from a female client who has anorexia nervosa, the nurse should expect a finding of low bone density.
Anorexia nervosa is an eating disorder characterized by self-starvation, distorted body image, and a fear of gaining weight. Clients with anorexia nervosa are at risk for severe malnutrition, which can lead to a variety of complications, including bone loss and osteoporosis.
Options A, B, and C are incorrect findings in a client with anorexia nervosa. Decreased cholesterol levels may be an indication of malnutrition. Heavy monthly periods, or menstrual irregularities, may occur in clients with anorexia nervosa because of the hormonal changes that can result from severe weight loss. Elevated serum potassium levels are not a common finding in a client with anorexia nervosa.
Correct Answer is A
Explanation
As clients with obsessive-compulsive disorder (OCD) often demonstrate repetitive behaviors to decrease anxiety. Cleaning or other repetitive behaviors help the client with OCD to cope with their anxiety by providing a sense of control over their environment.
Choice B, the client's wish to decrease the time available for interaction with others, is not a characteristic of OCD and does not explain the client's behavior. Choice C, the client's unconscious need to manipulate others, is a personality trait that is not associated with OCD.
Choice D, the client's delusion that cleaning is necessary, is not an accurate explanation for the behavior in this situation as the client is aware of their excessive cleaning behavior and it is not a delusion. The repetitive behavior is related to the client's anxiety, not a delusional belief.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today