A nurse is caring for a client who atempted suicide. Which of the following actions should the nurse take?

Serve meals with plastic utensils.

Assign another client to accompany the client to therapy sessions

Assign the client to a private room

Check on the client every 4 hr

Answer and Explanation

The Correct Answer is A

Answer: A

Rationale:

A) Serve meals with plastic utensils: Serving meals with plastic utensils is essential to reduce the risk of self-harm. Metal utensils could be used by the client to inflict injury upon themselves, so providing plastic utensils is a necessary safety measure to prevent potential harm.

B) Assign another client to accompany the client to therapy sessions: Assigning another client to accompany the client to therapy sessions is not appropriate as it places an undue burden on another client and may not ensure the safety of the at-risk client. Professional staff should provide supervision and support.

C) Assign the client to a private room: Assigning the client to a private room might increase the risk of self-harm due to reduced supervision. It is generally better to place the client in a more observable setting where staff can frequently monitor their condition.

D) Check on the client every 4 hr: Checking on the client every 4 hours is insufficient for someone who has recently attempted suicide. More frequent monitoring, such as constant or every 15-minute checks, is necessary to ensure the client's safety and provide immediate intervention if needed.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Answer: C. Change the perineal pad with each void.

Rationale:

A) Cleanse the perineal area from back to front: Cleansing from back to front is not recommended as it increases the risk of introducing bacteria from the anal area to the perineal wound, potentially leading to infection. The correct technique is front-to-back cleansing to prevent contamination.

B) Wash the perineal area with povidone-iodine twice daily: Povidone-iodine is not typically recommended for regular perineal care postpartum, as it can disrupt normal flora and potentially irritate the healing tissues. Using warm water and mild soap is safer for cleansing the area.

C) Change the perineal pad with each void: Changing the perineal pad with each void helps maintain cleanliness and reduces moisture in the perineal area, decreasing the risk of infection and promoting comfort during the healing process of an episiotomy.

D) Wipe the perineal area with a soft cloth: Wiping the area can disrupt the stitches and may cause discomfort. Instead, clients are usually advised to gently pat dry or use a squirt bottle to cleanse, which reduces pressure on the healing tissue.

A. Frequently remind the client of the expectations for her behavior. B. Encourage the client to participate in a group activity in the dayroom. C. Allow the client to pick her own choice of clothing. D. Encourage the client to increase physical activity during the day.

Correct Answer is A

Explanation

Answer: A. Frequently remind the client of the expectations for her behavior.

Rationale:

A) Frequently remind the client of the expectations for her behavior:

Clients experiencing mania may have difficulty maintaining appropriate behavior due to their heightened energy levels and impulsivity. Frequently reminding them of behavioral expectations helps provide structure and boundaries, which can promote a safer and more controlled environment.

B) Encourage the client to participate in a group activity in the dayroom:

While social interaction can be beneficial, clients in a manic state might be overly stimulated by group activities. This can exacerbate their symptoms, leading to increased agitation or disruptive behavior. It's often more appropriate to provide a calm and low-stimulation environment.

C) Allow the client to pick her own choice of clothing:

Allowing a manic client to choose their own clothing can lead to choices that are inappropriate for the setting or the weather, as judgment may be impaired during mania. Providing guidance in clothing choices can help ensure the client is dressed suitably and safely.

D) Encourage the client to increase physical activity during the day:

While physical activity is generally beneficial, clients in a manic state may already be overly active and may not need encouragement to increase their activity. Overexertion can lead to exhaustion and further exacerbate manic symptoms. It is often more beneficial to encourage activities that promote relaxation and calmness.

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