A nurse is caring for a client following a recent suicide attempt. Which of the following actions should the nurse take?
Initiate one to one constant supervision around the clock.
Ensure the client's hands are always visible.
Tuck bedcovers over client's hands and arms.
Inspect the client's personal belongings.
Check the environment for possible hazards.
Assign the client to a private room.
Place only plastic utensils on the client's meal tray.
Correct Answer : A,E
a. Initiate one to one constant supervision around the clock: A client who has attempted suicide is at high risk for further harm, and close monitoring is necessary to prevent further attempts. Initiation of one-to- one constant supervision around the clock ensures that the client is continuously monitored, and any signs of suicidal ideation or behavior can be immediately addressed.
e. Check the environment for possible hazards: It is important to check the client's environment for potential hazards, such as sharp objects, cords, or other items that could be used to harm oneself. This step helps to ensure the client's safety and prevent further attempts.
The other options are not appropriate or necessary in this situation:
b. Ensure the client's hands are always visible: This action may be necessary if the client has a history of self-harm or aggressive behavior, but it is not specifically related to preventing suicide attempts.
c. Tuck bedcovers over client's hands and arms: This action may be necessary if the client has a history of self-harm, but it is not specifically related to preventing suicide attempts.
d. Inspect the client's personal belongings: While it may be important to inspect the client's personal belongings for any items that could be used for self-harm, this action is not as urgent as initiating constant supervision and checking the environment for hazards.
f. Assign the client to a private room: While a private room may be beneficial for the client's comfort and privacy, it is not specifically related to preventing suicide attempts.
g. Place only plastic utensils on the client's meal tray: This action is not specifically related to preventing suicide attempts, unless there is concern that the client may harm themselves with utensils.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Russell’s sign is a physical symptom that is associated with bulimia nervosa. It refers to the presence of calluses on the knuckles or back of the hand that are caused by repeated self-induced vomiting.
Option a. Very low BMI is not typically associated with bulimia nervosa. People with bulimia nervosa may have a normal or above-normal BMI.
Option b. Decreased size of parotid glands is not associated with bulimia nervosa. In fact, people with bulimia nervosa may have an enlarged parotid gland due to repeated vomiting.
Option d. Fluid and electrolyte overload is not typically associated with bulimia nervosa. People with bulimia nervosa may experience fluid and electrolyte imbalances due to repeated vomiting and laxative abuse.
Correct Answer is D
Explanation
A full bladder can help improve the quality of an abdominal ultrasound by pushing the intestines out of the way and providing a clearer view of the uterus and baby.
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