A nurse is caring for a client diagnosed with schizophrenia following a recent suicide attempt. Which of the following actions should the nurse take?
Place metal utensils on the client's meal tray.
Assign the client to a private room.
Inspect the client's personal belongings.
Tuck bedcovers over client's hands and arms.
The Correct Answer is C
A) Incorrect. Placing metal utensils on the client's meal tray may pose a safety risk, especially considering the recent suicide attempt.
B) Incorrect. Assigning the client to a private room may be beneficial for privacy, but the more immediate concern is ensuring the safety of the client by inspecting personal belongings.
C) Correct. Inspecting the client's personal belongings is crucial to remove any potentially harmful items that the client may use to harm themselves.
D) Incorrect. Tucking bedcovers over the client's hands and arms is not a specific intervention related to the recent suicide attempt.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A schizophrenic episode Schizophrenic episodes are characterized by a complex interplay of symptoms including delusions, hallucinations, disorganized thinking, and altered perceptions. While the client is experiencing altered perceptions, the sudden onset and specific description are more indicative of hallucinogen ingestion.
B. Hallucinogen ingestion The client's description of altered perception, feeling outside of their own body, and visual distortions are indicative of hallucinogen ingestion. This class of substances can cause profound alterations in perception, leading to hallucinations and distorted sensory experiences. The slightly elevated vital signs may be a physiological response to the effects of the hallucinogen.
C. Opium intoxication Opium is an opioid and its effects are characterized by sedation, respiratory depression, and miosis (pupil constriction). The client's description of altered perception and feeling outside of their body are not typical of opium intoxication.
D. Cocaine overdose Cocaine is a stimulant and its effects are characterized by increased heart rate, blood pressure, and hyperarousal. The client's description of altered perception and feeling outside of their body are not typical of cocaine overdose.
Correct Answer is A
Explanation
A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This
intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.
B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.
C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.
D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.
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